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THE    AFTER-TREATMENT    OF 
OPERATIONS 


WORKS  BY  THE  SAME  AUTHOR 


DISEASES  OF  THE  COLON. 


/ 


DISEASES  OF  THE  RECTUM  AND 

ANUS. 


THE  SIGMOIDOSCOPE. 


THE  AFTER-TREATMENT 
OF    OPERATIONS 


a  noanual  for  practitioners  anb  Ibouec 
Surocons 


BY 

P.  LOCKHART-MUMMERY,  F.R.C.S.  Eng. 

B.A.,  M.B.,  B.C.   Cantab. 

Senior  Surgeon,  St.  Mark's  Hospital  /or  Cancer,  Fistula,  and  other  Diseases  of  the 

Rectu-m  ;   The  Queen's  H ospiial  for  Children,  London; 

and  Honorary  Stirgeon  to  King  Edward  Vllih's  Hospital  for  Officers; 

Special  Consulting  Surgeon  to  City  of  London  Military  Hospital  and  Fulhajn 

Military  Hospital; 

Jacksonian  Prizeman,  and  Late  Hunterian  Professor,  Royal  College  of  Surgeons 


FOURTH  EDITION 


NEW  YORK 
WILLIAM     WOOD     &     COMPANY 

MDCCCCXVI 


Printed  in  England 


PREFACE  TO  THE   FOURTH  EDITION 

The  continued  popularity  of  this  book  and  the  call  for  a 
fourth  edition  are  very  gratifying,  and  show  that  it  has, 
at  any  rate,  proved  of  real  value  to  those  readers  for 
whom  it  was  designed.  In  the  present  edition  much  new 
matter  has  been  added,  and  the  whole  book,  as  far  as  is 
possible,  brought  completely  up  to  date.  In  particular  the 
chapter  on  Surgical  Shock  has  been  entirely  rewritten  in 
the  light  of  more  recent  work  on  this  subject.  Although 
the  treatment  of  Gunshot  Wounds  is,  perhaps,  not  strictly 
within  the  scope  of  this  book,  there  are  so  many  medical 
men  at  present  acting  as  surgeons  in  charge  of  military 
hospitals  of  one  kind  or  another,  that  the  author 
thinks  a  chapter  on  this  subject  will  be  a  useful  addition, 
more  especially  as  he  has  received  requests  from  old 
readers  to  include  such  a  chapter  in  the  present  edition. 

A  very  natural  criticism  that  has  been  made  by  some 
reviewers  of  previous  editions  is,  that  while  the  after- 
treatment  of  some  operations  is  very  fully  described,  that 
of  others  is  only  scantily  treated.  The  author  wishes  to 
point  out  that  this  is  necessarily  so  in  a  work  of  this  size, 
as  without  greatly  enlarging  the  book  it  would  be  impos- 
sible to  describe  the  after-treatment  of  all  the  operations 
in  any  detail.     Operations  like  gastrostomy,  operations 


vl  Preface  to   the   Fourth   Edition 

on  the  brain,  and,  in  general,  those  which  are  only  per- 
formed by  expert  surgeons,  do  not  require  the  same 
detailed  consideration  here,  since  the  after-treatment 
of  these  cases  usually  is,  and  always  should  be,  under 
the  direct  supervision  of  the  operating  surgeon,  who, 
one  may  assume,  does  not  require  instruction  on  the 
subject.  The  after-treatment  of  the  more  common  and 
less  serious  operations  is,  as  far  as  possible,  described 
fully,  as  these  are  the  cases  in  which  the  after-treatment 
is  most  likely  to  be  left  to  the  general  practitioner  or 
house  surgeon. 

P.  LOCKHART-MUMMERY. 


9,  Hyde  Park  Place,  W. 

April,   1916. 


PREFACE  TO  THE  FIRST  EDITION 

The  after-treatment  of  operation  cases  is  a  subject  of 
such  importance  that  it  is  not  a  little  surprising  to  find 
how  little  has  hitherto  been  written  about  it.  What  has 
been  written  is  to  be  found,  for  the  most  part,  in  a  some- 
what fragmentary  form  in  the  larger  text-books,  and  is 
not  convenient  for  reference. 

I  have  attempted  in  the  present  manual  to  put  the 
subject  in  a  useful  and  practical  form  for  ready  reference 
by  those  who,  having  to  treat  such  cases,  wish  to  know 
what  complications  may  be  expected,  and  how  they  are 
to  be  met  when  present. 

The  after-treatment  of  operation  cases  adopted  by 
different  surgeons  varies  very  considerably.  But  as  no 
good  purpose  would  be  served  by  a  recital  of  all  the 
different  methods,  I  have  given  in  each  case  that  line  of 
treatment  which  seems  to  be  the  most  practical,  and  have 
avoided  entering  into  any  discussion  upon  the  relative 
merits  of  the  different  forms  of  treatment  sometimes 
adopted. 

In  the  chapter  on  shock,  a  short  description  of  the  more 
recent  physiology  of  this  condition  has  been  included,  in 
the  hope  that  it  may  assist  the  reader  in  the  treatment  of 
this  most  important  complication. 


viii  Preface  to  the  First  Edition 

Considerable  space  has  been  devoted  to  the  after-treat- 
ment of  abdominal  cases,  as  it  is  here,  perhaps  more  than 
anywhere  else,  of  importance. 

I  have  to  offer  my  best  thanks  to  Mr.  Herbert  Ailing- 
ham  for  kindly  looking  through  the  manuscript,  and  to 
those  others  of  my  friends  Mrho  have  assisted  me. 

P.  LOCKHART-MUMMERY. 

September,  1903. 


CONTENTS 

CHAPTER  P/VGE 

I.    INTRODUCTORY                   .                 .                 .                 .  i 

II.    TREATMENT   OF    THE    WOUND     -                  -                  '  ^5 

III.  TREATMENT    OF    GUNSHOT    WOUNDS  -  "43 

IV.  HAEMORRHAGE    AFTER    OPERATIONS          -                  "  5^ 
^^y.    SURGICAL    SHOCK               -                  -                  -                  "74 

VI.    POST-AN.«STHETIC   COMPLICATIONS           -                 -  Q7 

VII.    THROMBOSIS    FOLLOWING   OPERATIONS  -                 -  Io6 

VIII.    POSTOPERATIVE   RASHES   AND   DRUG-POISONING  Il6 
IX.    OPERATIONS      ON      THE       MOUTH,      NOSE,      AND 

PHARYNX        -                  -                  -                  -                  -  131 

X.    OPERATIONS    ON    THE    HEAD        -                  -                  -  14I 

XI.    OPERATIONS    ON    THE    NECK         -  -  "149 

XII.    OPERATIONS    ON    THE    THORAX  -                  -                  -  158 

XIII.    OPERATIONS      ON      THE      ABDOMEN  GENERAL 

TREATMENT    AND    COMPLICATIONS       -                  -  1 69 

XIV.    OPERATIONS    ON    THE    ABDOMEN    {contitiued)        -  1 97 

X.V.    OPERATIONS    ON   THE   GENITO-URINARY   TRACT-  215 

XVI.    OPERATIONS    ON    THE    RECTUM,   AND    COLOTOMY  228 

XVII.    OPERATIONS    ON    THE   JOINTS      -                  -                  -  239 

XVIII.    THE   AFTER-TREATMENT    OF  AMPUTATIONS,   AND 

SOME    SPECIAL    OPERATIONS  -                  -                  -  250 

APPENDIX             -                 -                 -                 -                 -  264 


INDEX 


273 


IX 


THE    AFTER-TREATMENT 
OF   OPERATIONS 


CHAPTER  I 

INTRODUCTORY 

The  after-treatment  of  operation  cases  is  one  of  the  most 
interesting  studies  in  surgery,  and  at  the  same  time  one 
of  the  most  important.  Nothing  will  better  repay  care- 
ful and  intelligent  observation  by  those  having  such  cases 
under  their  care.  Whether  an  operation  is  successful  or 
otherwise  depends,  of  course,  to  a  large  extent  upon  the 
manner  in  which  the  operation  is  carried  out  and  upon 
the  skill  of  the  operator,  but  it  also  depends  to  no  small 
extent  upon  the  care  and  attention  which  is  paid  to  the 
after-treatment.  The  operation  is  the  most  showy  and 
impressive  part  of  the  treatment  of  the  disease  or  con- 
dition, and,  in  consequence,  it  has  become  too  common 
to  think  that  the  operation  is  everything,  and  that  the 
after-treatment  is  merely  a  matter  of  course.  This  is, 
however,  not  the  case.  Many  operations  depend  for  their 
success  on  the  way  in  which  the  treatment  afterwards  is 
carried  out,  and  many  an  almost  hopeless  case  has  been 
saved  by  skilful  after-treatment. 


2     The  After-Treatment  of  Operations 

To  no  branch  of  medicine  or  surgery   does  the   old 
maxim    '  Prevention   is   better   than   cure '  apply  more 
aptly  than  it  does  here.     The  best  results  will  always  be 
obtained  by  anticipating  complications,  and  taking  steps 
to  prevent  their  occurrence,  rather  than  by  treating  them 
after  they  are  well  established.     Our  line  of  treatment 
should  be  to  put  the  patient  under  the  most  favourable 
circumstances   for   rapid   recovery,    and   by   bearing   in 
mind   the    complications    that    are    liable    to    occur,    to 
anticipate  them,  and  so  treat  the  patient  that  they  are 
avoided.     A  surgeon  may  perhaps  get  great  credit  for 
saving  a  patient  by  brilliant  treatment  when  he  is^  in 
extremis,  but  the  best   surgeon  will,  nevertheless,  be  he 
whose  patient  has  never  got  into  this  condition.  Artificial 
conditions   should   be   avoided   as   far   as  possible,  and 
when  a  patient  has  a  natural  desire  for  any  particular 
thing,  it  should  be  gratified,  unless  there  is  some  reason- 
able objection  to  doing  so.     Nature  is,  after  all,  the  best 
judge  of  what  is  good  for  a  patient  or  what  is  not  good, 
and,  as  a  rule,  the  patient  will  not  wish  for  those  things 
which  are  dangerous  in  his  condition.     There  should  be 
a  definite  reason  for  e^ery  course  of  treatment,  and  rule- 
of-thumb  methods  must  especially  be  avoided.     No  two 
cases  are  exactly  alike,  even  after  an  almost  identical 
operation,    and   exactly   the   same   treatment   need   not 
necessarily   be    adopted.      When,    after    an    operation, 
complications   occur,   the   treatment  should   be  prompt 
and  thorough.     Meddlesome  interference,  however,  must 
be  avoided,  and  as  long  as  the  patient  is  doing  wxll  he 
should  be  left  alone.     The  after-treatment  of  operations 
may  be  said  to  be  the  study  of  details,  and  the  two  most 
useful  adjuncts  to  success  are  careful   observation   and 
common-sense.     There  is  a  saying  of  the  great  physician 
Sydenham  which  is  well  worth  bearing  in  mind :  '  More 


Introductory  3 

importance  is  to  be  attached  to  the  desires  and  feelings 
of  the  patient,  provided  that  they  are  not  excessive,  than 
to  the  doubtful  and  fallacious  rules  of  medical  art.' 


The  Importance  of  Posture  in  the  After-Treatment 
of  Operation  Cases. 

It  seems  to  have  become  an  accepted  dictum  with 
many  people  that,  after  operations  of  a  certain  degree 
of  severity,  the  proper  position  to  nurse  the  patient  in 
is  the  dorsal  recumbent  one.  This  seems  to  have  been 
assumed  on  somewhat  insufficient  grounds.  As  regards 
the  comfort  of  the  patient,  this  position  is  not  a  success. 
It  is  not  a  natural  position.     Few  people  sleep  on  their 


'ILliiLLd ' ^f'ni.'ifi  I  iiiiM I  nMiiiiif,'mj_)j_/i'(ii(ii(i/('/i/^ 

Fig.  I. — Dorsal  Recumbent  Position. 

backs,  and  when  those  who  are  unaccustomed  to  it  are 
obliged  to  do  so  they  are  often  unable  to  sleep  well.  It 
is  a  very  common  experience  to  hear  patients  who  are 
under  treatment  for  fractures  or  some  other  complaint 
necessitating  the  dorsal  position  complain  that  their 
backs  hurt  them  more  than  the  injury,  and  who  say  that 
they  would  be  quite  comfortable  if  they  were  allowed  to 
turn  on  to  their  side.  Often  their  only  complaint  is  the 
discomfort  of  the  position. 

The  recumbent  position  on  the  back  is  not  anatomi- 
cally sound.  The  skin  covering  the  sacrum  and  lower 
lumbar  region  is  very  badly  supported  for  withstanding 

I — 2 


4     The  After-Treatment  of  Operations 

continuous  pressure.  The  sacrum  is  very  superficial, 
and  in  the  majority  of  individuals  there  is  but  little  fat 
and  muscle  between  it  and  the  skin.  The  same  may 
also  be  said  of  the  other  bony  points  on  the  back.  The 
angle  of  the  spine  of  the  scapula  is  just  beneath  the  skin, 
and  but  slightly  covered.  The  spines  of  the  vertebrae 
also  are  immediately  beneath  the  skin,  and  the  latter  is 
unduly  subjected  to  pressure,  owing  to  the  prominent 
position  of  the  spines.  There  are  many  other  objections 
to  the  position.  Women  who  are  kept  long  in  this 
position  are  very  liable  to  develop  cystitis  from  the 
presence  of  residual  urine  in  the  bladder,  as  most  women 
are  unable  to  empty  their  bladders  completely  when 
lying  on  their  backs.  This  fact  should  be  remembered, 
as  it  is  a  very  common  cause  of  cystitis  in  women  after 
operations.  It  may  be  prevented  by  passing  a  catheter 
occasionally,  but  a  much  better  way  is  to  allow  the 
patient  to  turn  on  to  her  side  in  order  to  micturate,  or,  if 
possible,  to  sit  up  for  the  purpose. 

The  Prone  Position  (Fig.  2). — This  is  often  very 
much  better  than  the  dorsal  position,  and  is  particularly 
suitable  when  it  is  desired  to  drain  a  wound  opening 
upon  the  anterior  surface  of  the  body,  as  in  some  cases 
of  appendix  abscess,  psoas  abscess,  etc.,  or,  again,  when 
the  dorsal  position  has  resulted  in  the  formation  of  bed- 
sore, or  it  is  feared  will  do  so.  In  this  position  the 
patient  lies  on  the  face  with  a  pillow  under  the  chest, 
and  another  is  placed  to  rest  the  side  of  the  head  upon. 
Patients  soon  become  accustomed  to  this  position,  and 
often  find  it  more  comfortable  when  unable  to  move  than 
the  dorsal  one.  The  front  of  the  body  is  well  provided 
against  pressure,  and  bed-sores  are  practically  never 
seen.  (The  knees  are  the  only  places  where  sores  are  at 
all  likely  to  occur.)     The  tendency  to  distension  of  the 


Introductory 


abdomen,  which  is  common  in  the  dorsal  position,  and 
especially  when  the  patient  is  on  a  fluid  diet,  is  much  less, 
and  the  cystitis  just  mentioned  in  connection  with  the 
dorsal  position  in  women  does  not  occur,  as  the  bladder 
is  able  to  empty  itself  easily  by  gravity. 

The  late  Mr.  AUingham  also  pointed  out  the  value  of 
this  position  after  injury  to  the  main  femoral  vessels. 
Under   such   circumstances   the    integrity   of    the    limb 


Fig.  2. — Prone  Position, 


depends  upon  the  rapid  development  of  a  collateral  cir- 
culation, and  it  is  therefore  of  the  greatest  importance 
that  the  collateral  vessels  should  be  relieved  from  all 
pressure.  As  many  of  these  collateral  vessels  are  in  the 
gluteal  region  and  back  of  the  thigh,  the  dorsal  position  is 
very  unsuitable  to  this  end,  and  the  prone  position  should 
be  adopted.  Mr.  AUingham  had  a  case  where  it  was 
necessary  to  resect  a  portion  of  both  the  main  femoral 
vessels  in  removing  a  tumour  of  the  femur,  and  in  which 
the  prone  position  was  adopted  ;  the  collateral  circulation 
was  soon  established,  and  the  limb  recovered  perfectly. 

Semi-recumbent  Position  (Fig.  3). — Here  the  patient 
is  propped  up  into  a  half-sitting  posture  with  pillows  and 
a  bed-rest ;  a  bolster  is  also  placed  under  the  thighs  to 
prevent  the  patient  from  slipping  down  in  the  bed.  Care 
must  be  taken  to  see  that  there  is  not  undue  pressure 


6     The  After-Treatment  of  Operations 

on  the  lower  part  of  the  sacrum,  otherwise  bed-sore  is  apt 
to  occur  at  this  spot ;  this  may  be  prevented  by  flexing  the 
knees  over  a  bolster  or  junk,  and  allowing  the  weight  to 


Fig.  3. — Semi-recumbent  Position. 


be  taken  on  the  under-surfaces  of  the  thighs.  The 
bolster  should  be  a  stiff  one  (a  good  size  is  3  feet  long 
by  9  inches  diameter),  and  should  be  attached  to  the 
head  of  the  bed  at  either  end  with  straps.  A  good  sub- 
stitute can  be  made  by  wrapping  a  blanket  round  a 
broomstick  and  tying  the  ends  of  the  latter  to  the  head 
of  the  bed. 

This  is  the  position  in  which  all  elderly  people  should 
be  nursed  whenever  possible.  The  recumbent  position 
is  particularly  unsuitable  for  such  patients,  as,  although 
their  lungs  may  have  been  previously  healthy,  they  are 
very  liable  to  develop  a  moist  bronchitis  or  hypostatic 
congestion  of  the  lungs  if  kept  lying  down  for  any  length 
of  time,  and  this  is  particularly  the  case  when  the  opera- 
tion interferes  with  the  thoracic  or  diaphragmatic  move- 
ments, as  after  removal  of  the  breast  or  operations  on 


Introductory 


7 


the  stomach,  etc.  This  position  is  the  best  after  most 
operations  on  the  stomach,  after  operations  on  the  thorax, 
and  many  others  which  will  be  mentioned  later.  It  is 
also  preferable  to  the  recumbent  position  in  many  cases 
of  weak  or  failing  circulation,  when  this  weakness  or 
failure  is  in  any  way  dependent  upon  deficient  aeration 
of  the  blood  in  the  lungs.  This  is  probably  to  be  ac- 
counted for  by  the  greater  freedom  of  the  chest  move- 
ments allowed  by  the  position.  This  is  also  the  position 
in  which  all  patients  should  be  nursed,  if  possible,  who 
are  suffering  from  peritonitis  or  in  whom  this  complica. 
tion  is  feared.  It  allows  tke  products  of  inflammation 
within  the  abdominal  cavity  to  gravitate  into  the  pelvis, 
where  they  will  do  least  harm  and  can  be  most  easily 
and  safely  dealt  with.  This  is  now  often  called  '  the 
Fowler '  position. 


Fig.  4. — Lateral  Position. 

The  Lateral  Position  (Fig.  4). — This  is  the  natural 
resting  position  of  most  people,  and  it  is  the  most  com- 
fortable position  for  many  patients  when  circumstances 
will  allow  of  its  being  permitted.  The  patient  lies  on  the 
side  with  the  under-knee  well  flexed  and  the  upper  one 
slightly  so ;  the  trunk  should  also  be  a  little  flexed. 
Many  patients  are  rendered  more  comfortable  if  a  pillow 
or  bolster  is  put  to  support  the  back. 

Position  after  Laparotomy. — It  has  been,  and  to  a 


8     The  After-Treatment  of  Operations 

large  extent  still  is,  customary  to  consider  that  the  best 
position  for  patients  after  abdominal  section — at  any  rate 
for  the  first  few  days — is  lying  on  their  backs ;  this  is, 
however,  unnecessary  and  inadvisable  except  in  special 
cases.  Comfort  and  sleep  are  here  of  the  greatest  impor- 
tance, and  if  the  patient  can  be  got  quietly  to  sleep  during 
the  first  twenty-four  hours  after  the  operation,  much  will 
have  been  gained.  As  it  is  advisable  in  these  cases  to 
avoid  the  use  of  opiates  as  much  as  possible,  it  becomes 
all  the  more  important  to  secure  the  patient's  comfort. 
Patients  after  laparotomy  are,  as  a  rule,  much  easier  if 
allowed  to  turn  on  to  the  side ;  they  should  be  moved  on 
to  that  side  on  which  they  are  accustomed  to  sleep,  and 
carefully  assisted  into  the  position  which  they  find  most 
comfortable,  and  in  many  cases  they  will  drop  off  to  sleep 
in  a  few  minutes.  No  harm  to  the  wound  need  be 
apprehended,  and  the  position  on  the  side  with  the  knees 
well  drawn  up,  by  relaxing  the  recti  muscles,  often  gets 
rid  of  the  pain  which  sometimes  follows  the  operation. 
This  pain  is  no  doubt  often  due  to  spasm  of  the  abdominal 
muscles  resulting  from  the  traumatism,  and  relaxing  these 
muscles  by  slightly  flexing  the  trunk  is  often  quite  enough 
to  stop  the  pain.  When  the  abdominal  wound  is  to  one 
side  and  has  not  been  closed,  as  in  colotomy  and  appendix 
abscess,  it  is  best  not  to  allow  the  patient  to  turn  on  to 
the  wounded  side,  as  this  might  result  in  prolapse  of  the 
intestine ;  he  may,  however,  be  turned  on  to  the  opposite 
side  with  safety. 

After  abdominal  section  in  children  it  is  particularly 
important  that  no  unnecessary  restraint  should  be  insisted 
upon.  No  child,  unless  it  is  very  ill  indeed,  will  remain 
for  long  in  the  recumbent  position  without  constant 
watching  or  the  use  of  some  retentive  apparatus  ;  and 
constraint   soon  renders   children  restless  and  irritable. 


Introductory  9 

and  prevents  them  sleeping.  If  allowed  to  move  about 
as  they  choose  they  seldom  come  to  any  harm,  and,  as  a 
rule,  keep  much  quieter  than  if  subjected  to  restraint. 
In  young  children  it  is  best  to  fix  the  dressing  with 
broad  pieces  of  strapping  encircling  the  body ;  this  pre- 
vents the  movement  of  the  child  from  disturbing  the 
dressings,  and  at  the  same  time  supports  the  stitches. 
When  it  Is  necessary  to  keep  a  child  on  its  back  for  any 
length  of  time,  a  preferable  method  to  the  use  of  shoulder 
straps  is  to  apply  extension  strapping  to  the  child's  legs 
and  to  sling  both  legs  up  to  a  cross-bar,  as  in  the  treat- 
ment of  fractured  femur  by  Bryant's  method.  This  is  a 
much  more  effectual  method  than  the  use  of  shoulder 
straps,  and  children  do  not  object  to  it  so  much ;  it  also 
enables  the  child  to  be  kept  clean  very  easily. 

As  little  restraint  as  possible  should  be  put  upon  a 
child's  movements  after  an  operation,  and  the  younger 
the  child  the  more  important  this  becomes. 

Lastly,  it  should  always  be  remembered  in  connection 
with  the  position  of  a  patient  after  an  operation,  that  the 
position  of  greatest  comfort  is  also  that  of  greatest  rest, 
and  therefore  the  best. 

Illustrative  Case. — A  child,  aged  six  months,  was  admitted  to 
the  hospital  for  acute  intussusception.  Abdominal  section  was 
performed,  and  a  large  ileo-csecal  intussusception  found  which 
involved  nearly  the  whole  of  the  large  intestine  ;  the  bowel  was 
black  and  oedematous,  but  still  shiny.  This  was  reduced  and  the 
abdomen  closed  with  fisii-gut  sutures.  The  operation  took  about 
twenty-five  minutes.  Two  broad  pieces  of  strapping  were  fixed 
round  the  child's  body  over  the  first  layer  of  dressings,  so  as  to 
take  the  strain  off  the  stitches.  Previous  to  the  operation  the  child 
had  been  entirely  breast-fed.  After  the  operation  the  child  was 
not  weaned,  but  was  taken  out  of  the  cot  by  its  mother  and  put  to 
the  breast  every  three  or  four  hours.  The  first  feed  was  given  six 
hours  after  the  operation.  The  child's  movements  were  not 
restrained  in  any  way,  and  it  was  fed  exactly  as  if  no  operation  had 


10     The  After-Treatment  of  Operations 

been  performed.  In  spite  of  its  youth  and  the  damaged  condition  of 
the  bowel  it  made  an  uninterrupted  recovery,  and  left  the  hospital  on 
the  sixteenth  day. 

Sleeplessness  after  Operations. 

This  may  be  due  to  a  variety  of  causes,  and  must  be 
treated  accordingly.  When  due  to  pain,  morphia  must 
usually  be  given  so  as  to  secure  a  good  night's  rest, 
The  commonest  cause  is  undoubtedly  discomfort,  and 
everything  should  be  done  to  make  the  patient  as  com- 
fortable as  is  possible  under  the  circumstances.  If  the 
patient  complains  that  the  bandages  are  too  tight,  these 
may  be  loosened  a  little  ;  if  he  finds  his  position  uncom- 
fortable, he  should  be  moved  into  a  new  one,  and  especially 
into  that  position  in  which  he  is  accustomed  to  sleep  ;  if 
he  is  thirsty,  he  should  be  allowed  a  drink  of  water,  milk, 
or  lemonade,  etc.  An  ounce  of  whisky  or  brandy  given 
in  hot  water  will  often  act  as  a  most  effectual  sleeping- 
draught,  and  can  be  very  seldom  contra-indicated.  A 
very  useful  sleeping-draught  for  use  after  operations  is 
the  following  : 

^  Liq.  morphinje  tartratis      ...    ntxxv. 
Aquam  pimentae       -  -  -  -     ad  gi. 

If  morphia  is  not  advisable  chloral  may  be  given,  or 
any  of  the  numerous  drugs  which  are  now  in  use  for 
insomnia  ;  of  these  trional  is  one  of  the  best,  and  should 
be  given  in  20-grain  doses ;  it  is  often  rendered  more 
effective  if  administered  with  a  little  whisky  and  hot 
water.  Paraldehyde  is  a  very  effective  drug,  but  owing 
to  its  unpleasant  property  of  making  the  patient's  breath 
smell  it  often  cannot  be  used  ;  it  should  be  administered 
in  peppermint  water  with  some  syrup  to  disguise  the  ta-ste: 

^  Paraldehyde  -  .  >  .    3i.ss. 

Tinct.  aurantii  .  _  _  .    gij, 

Aqus  menth.  pip.   -  .  -  -    gi.ss. 


Introductory  1 1 

It  is  always  better  to  avoid  the  use  of  sleeping-draughts 
if  possible,  and  they  should  never  be  made  use  of  as  a 
routine  practice. 

Pain  after  Operations. 

A  certain  amount  of  pain  after  an  operation  is  common, 
and  may  be  due  to  a  variety  of  different  causes,  such  as 
tightly  tied  sutures,  tight  packing  with  gauze,  powerful  • 
antiseptics  in  contact  with  exposed  nerve-endings,  etc. 
In  an  ideal  operation  on  a  healthy  subject  there  should 
be  no  pain  afterwards,  and  after  many  operations,  where 
healthy  tissues  have  been  cleanly  cut,  there  is  no  pain. 
Unfortunately,  a  certain  amount  of  pain  is  the  rule  after 
most  operations,  and  it  ought  to  be  our  object  to  prevent, 
or  at  least  ameliorate,  this  as  far  as  possible.  There  is 
probably  nothing  which  will  make  patients  more  grateful 
or  bring  the  surgeon  more  credit  than  the  relief  of  pain 
after  an  operation  ;  and  if  patients  find  that  they  can 
undergo  operations  without  suffering  pain,  much  will 
have  been  done  in  making  operations  less  dreaded  by  the 
general  public  than  they  are  at  present. 

Pain  is  due  to  the  stimulation  of  nerve-tissue,  and  more 
especially  of  nerve-endings,  and  in  a  clean-cut  wound  this 
stimulation  ceases  when  the  cutting  is  finished  ;  any  pain 
that  occurs  after  that  is  either  the  result  of  movement  in 
the  part  wounded  or  of  tension,  and  in  some  cases  of 
stimulation  of  the  nerve  elements  by  irritants.  Move- 
ment taking  place  in  the  wound  can  be  guarded  against 
by  proper  splinting,  etc.,  except  in  the  neighbourhood  of 
the  thorax,  where  it  is  more  or  less  inevitable.  Tension 
may  occur  in  several  ways  :  it  may  be  from  too  tight 
splints  or  bandages,  or  tight  sutures  ;  in  many  cases  it  is 
due   to   congestion  and   swelling  of  the    tissues  of  the 


12     The  After-Treatment  of  Operations 

wound.  Pain  from  this  cause  is  particularly  well  marked 
in  acute  inflammation.  Thus,  during  the  formation  of  an 
acute  abscess,  the  tension  in  the  abscess  causes  pressure 
upon  the  nerve-endings,  and  pain  is  the  result,  the 
severity  of  the  latter  being  proportionate  to  the  elasticity 
and  nerve-supply  of  the  part  affected.  Thus,  when  acute 
inflammation  attacks  the  tightly  bound  down  skin  of  the 
nose  (as  when  boils  occur  at  the  margin  of  the  nostril), 
or  the  pulp  of  the  finger  (as  is  the  case  in  whitlow  in  this 
neighbourhood),  the  pain  is  out  of  all  proportion  to  the 
severity  of  the  inflammation.  A  certain  amount  of 
inflammation  is  set  up  locally  after  any  traumatism,  and 
it  is  the  congestion  resulting  from  this  that  gives  rise  to 
the  pain  in  most  cases. 

In  order,  therefore,  to  prevent  pain  after  operations, 
we  should  try  to  relieve  this  local  congestion.  The  most 
effectual  way  of  doing  this  is  by  elevation  of  the  part. 
The  pain  which  often  follows  amputations  is  often  much 
reheved  by  well  elevating  the  stump.  Any  bandages  or 
clothes  which,  by  pressing  upon  the  veins  on  the  proximal 
side  of  the  wound  may  tend  to  keep  up  this  congestion, 
should  be  loosened.  By  keeping  in  mind  this  cause  of 
pain,  much  may  often  be  done  by  the  simplest  means  to 
relieve  the  pain  following  operations. 

Another  cause  of  pain  after  operations  is  spasm  of  the 
muscles  in  the  neighbourhood  of  the  wound.  This  spasm 
sometimes  causes  intense  pain,  and  prevents  the  patient 
going  to  sleep.  Pain  from  this  cause  can  often  be  pre- 
vented, if  the  affected  muscles  are  in  the  limbs,  by  flexing 
the  joints  or  altering  the  position  of  the  limb  so  as  to 
relax  the  affected  muscles.  Spasm  is  much  more  likely 
to  occur  in  a  tense  than  in  a  relaxed  muscle,  Gentle 
smooth  rubbing  of  the  muscles,  if  it  can  be  carried  out, 
will  immediately  and  effectually  stop  this  spasm. 


Introductory  1 3 

The  value  of  heat  for  relieving  pain,  applied  either  in 
the  form  of  fomentations  or  stupes,  is  well  known,  and  it 
may  sometimes  be  made  use  of  in  these  cases.  Unfortu- 
nately, it  is  seldom  possible  to  make  use  of  fomentations 
or  stupes  for  the  relief  of  pain  after  operations,  as  the 
wound  is  covered  up  with  dressings  which  it  is  not 
advisable  to  remove.  Cold  applied  by  means  of  an 
ice-bag  may  sometimes  be  used  ;  after  operations  upon 
joints,  such  as  the  knee,  it  is  often  efficacious  in  relieving 
the  pain.  A  heavy  ice-bag  should  not  be  allowed  to  rest 
upon  the  wound,  as  its  weight  will  cause  more  pain  than 
the  cold  will  relieve.  The  bag  must  be  suspended  from 
a  cradle  or  some  other  arrangement  made  to  take  the 
weight  off  the  wound. 

There  are  certain  operations  after  which  pain  is  gener- 
ally severe  for  a  time.  Operations  involving  interference 
with  bones  seem  to  be  peculiarly  liable  to  be  followed  by 
severe  pain,  and  especially  such  operations  as  excision  of 
joints.  Well-fitting  splints  which  are  not  too  tight  and 
elevation  of  the  limb  will  do  much  to  relieve  the  pain  in 
these  cases,  but  morphia  is  often  necessary  as  well.  The 
pain  can  often  be  relieved  in  such  cases  by  giving  aspirin 
in  10  grain  doses  every  six  or  eight  hours,  beginning 
with  5  grains  directly  after  the  operation.  The  pain 
after  operations  on  the  stomach  or  intestines  is  best 
relieved  by  small  doses  of  morphia  or  laudanum  given 
by  the  mouth. 

Drugs  should  not  be  given  indiscriminately  for  the 
relief  of  pain,  but  should  only  be  made  use  of  when  other 
means  fail,  or  in  conjunction  with  them.  Opium  in  some 
form,  and  especially  its  derivative  morphia,  is  the  most 
valuable  drug  we  possess  for  this  purpose,  but  there  are 
several  other  drugs  which  are  sometimes  of  value. 
Phenacetin  in  15  to  20  grain  doses  will  often  relieve  pain 


14     The  After-Treatment   of  Operations 

if  not  very  severe,  and  is  a  very  safe  drug  to  give,  or 
Trional  may  be  used.  Forty  grains  of  chloralamide 
placed  on  the  back  of  the  tongue  is  sometimes  very 
effectual  in  stopping  restlessness  and  procuring  sleep. 
In  all  severe  pain,  however,  morphia  should  be  given  in 
doses  from  ^  to  ^  grain  hypodermically,  unless  contra- 
indicated  for  some  other  reason.  The  dose  of  morphia 
that  has  to  be  given  varies  very  considerably,  both  as 
regards  the  individual  and  as  regards  the  severity  of  the 
pain,  and  it  is  well  to  bear  this  in  mind.  In  some  cases 
a  small  dose  is  quite  as  effectual  as  a  much  larger  one 
would  be ;  too  small  a  dose,  however,  will  in  many 
people  produce  restlessness  and  excitement.  Morphia 
must  never  be  given  continuously  for  more  than  a  few 
days,  as  there  is  great  danger  of  setting  up  the  morphia 
habit.  A  week  is  probably  the  outside  that  it  is  safe  to 
continue  using  the  drug,  without  either  intermitting  the 
dose  or  reducing  it.  The  pain  after  operations  usually 
ceases  after  twenty-four  or  thirty-six  hours  at  most ;  but 
when  it  does  not  do  so,  and  it  is  necessary  to  continue 
the  administration  of  morphia  for  its  relief,  the  best  plan 
after  the  first  two  or  three  days  is  to  either  reduce  the 
dose  by  a  half  or  to  give  an  injection  of  plain  water 
instead  of,  and  at  the  time  for,  the  usual  morphia  injec- 
tion. The  moral  effect  of  this  renders  it  often  quite  as 
effectual  as  the  morphia  would  be,  and  this  does  not  apply 
only  to  neurotic  individuals ;  the  most  strong-minded 
people  will  often  be  quite  satisfied  by  an  injection  of 
sterilized  water  if  they  imagine  that  it  is  morphia  and  it 
is  given  at  the  usual  time.  The  results  of  the  continuous 
use  of  morphia  are  so  bad  and  so  common  that  the 
greatest  care  must  be  taken  to  prevent  the  habit  being 
established,  and  such  an  innocent  deception  is  therefore 
perfectly  justifiable. 


Introductory  15 

Smoking"  and  Drug  Habits. 

Patients  often  ask  how  soon  they  may  be  allowed  to 
smoke  after  an  operation,  and  many  patients  are  very 
anxious  to  be  allowed  their  pipe  or  cigarette. 

Unless  there  is  some  obvious  contra-indication,  such 
as  is  the  case  after  operations  upon  the  throat  or 
pharynx,  it  is  advisable  to  allow  them  to  smoke  in 
moderation  as  soon  as  they  express  a  desire  to  do  so. 

Smoking  often  makes  a  patient  more  contented,  and 
so  adds  to  his  general  comfort  and  well-being. 

It  is  never  wise  to  entirely  stop  the  use  of  tobacco  in 
the  case  of  a  patient  who  is  an  habitual  heavy  smoker. 
Under  such  circumstances  the  sudden  abstinence  in  the 
use  of  tobacco  is  very  liable  to  cause  insomnia  and 
indigestion,  besides  often  making  the  patient  miserable 
and  discontented. 

The  same  also  applies  to  other  drugs.  Thus  a  patient 
who  is  accustomed  to  take  large  quantities  of  alcohol 
daily  should  not  be  entirely  forbidden  his  accustomed 
stimulant,  but  should  be  allowed  alcohol  in  moderation. 

And  in  the  case  of  a  morphia  maniac  it  is  never  wise 
to  stop  the  use  of  the  drug  or  even  to  reduce  the  dose; 
the  patient  should  be  allowed  his  ordinary  daily  dose  of 
morphia  at  the  time  at  which  he  is  accustomed  to  have 
it.  These  patients  are  always  bad  subjects  for  opera- 
tions, but  it  not  infrequently  happens  that  it  is  necessary 
to  operate  upon  them,  and  the  risks  of  the  operation  are 
much  increased  if,  at  the  same  time,  the  drug  is  stopped. 

It  must  always  be  remembered  when  dealing  with  a 
patient  who  is  the  slave  of  any  drug,  whether  it  be 
tobacco,  alcohol,  or  morphia,  that  from  long  habit  his 
normal  condition  of  both  mental  and  bodily  equilibrium 
is  that  in  which  he  is  more  or  less  under  the  influence  of 


i6     The  After-Treat ment  of  Operations 

his  particular  drug  ;  and  that  to  suddenly  make  him  an 
abstainer  is  to  change  him  into  an  abnormal  state. 

I  am  sure  that  the  only  satisfactory  way  of  obtaining 
good  results  from  operations  performed  upon  such 
patients  is  by  assuming  that  their  normal  condition  is 
when  under  the  influence  of  their  particular  drug,  and  to 
treat  them  accordingly. 

Thirst. 

Thirst  is  a  very  common  complaint  of  patients  after  an 
operation.  This  thirst  is  no  doubt  partly  due  to  an 
actual  loss  of  fluid  from  the  body.  There  is  generally 
free  perspiration  either  during  or  immediately  after  an 
operation  ;  the  salivary  glands  also  secrete  freely,  and 
there  may  have  been  fluid  in  the  shape  of  blood  or 
serum  lost  from  the  wound,  so  that  the  total  fluids  lost 
from  the  circulation  during  a  long  operation  may  be  con- 
siderable. Also  after  operations  of  any  degree  of  severity 
there  seems  to  be  a  tendency  for  the  secretion  of  mucus 
from  the  mucous  membranes  to  be  inhibited  for  a  time. 
This  results  in  the  mucous  membrane  of  the  mouth  being 
dry,  and  makes  the  patient  feel  thirsty. 

The  practice  of  only  allowing  patients  after  an  opera- 
tion to  have  sips  of  hot  water  is  to  be  deprecated.  It  is 
neither  sound  in  theory  nor  practice.  The  body  is  in  need 
of  fluid,  and  nothing  is  to  be  gained  by  withholding  it. 
Unless  there  is  some  very  definite  contra -indication, 
which  is  but  seldom  the  case,  the  patient  should  be 
allowed  to  slake  his  thirst  with  water  or  any  other  suit- 
able fluid,  the  only  restriction  being  that  a  large  quantity 
is  not  swallowed  at  one  time  (the  quantity  should  not 
be  more  than  i  pint  at  a  time).  The  contention  raised 
against  the  practice  of  allowing  fluids  in  proper  quantities 
is  that  it  causes  sickness.     As  a  matter  of  fact,  it  does 


Introductory  17 

not  often  do  so,  and  when  it  does  the  fluid  is  beneficial  in 
washing  out  the  stomach,  and  the  patient  is  much  more 
comfortable  afterwards ;  while,  on  the  other  hand,  sips 
of  hot  water  are  just  as  liable  to  cause  vomiting,  and 
neither  satisfy  the  patient's  thirst  nor  wash  out  his 
stomach  if  he  is  sick.  Hot  tea  is  often  very  comforting, 
and  can  do  no  harm ;  a  good  plan  is  to  give  a  cup  of 
weak  tea  with  a  sliee  of  lemon  and  a  little  sugar  in  it. 
Thirst  should  be  looked  upon  as  the  natural  call  of  the 
body  for  more  fluid,  which  may  be  administered  either 
by  the  mouth  or  rectum,  according  to  circumstances.  It 
is  difficult  to  see  how,  apart  from  its  causing  sickness, 
water  can  do  harm  under  any  circumstances,.  It  needs 
no  digestion,  and  does  not  cause  peristalsis. 

When  thirst  is  troublesome,  and  there  is  some  reason 
which  renders  it  inadvisable  to  give  fluid  by  the  mouth 
in  any  quantity,  large  warm-water  enemata  should  be 
given.  Many  surgeons  make  a  practice  of  giving  a 
warm  saline  injection  per  rectum  immediately  after 
any  long  operation  ;  this  is  an  excellent  plan.  The 
practice  of  filling  the  abdominal  cavity  with  warm  saline 
solution  before  closing  the  wound  is  a  most  effectual 
way  of  preventing  the  thirst  which  so  commonly  follows 
abdominal  operations ;  and  this  method  is  still  used  by 
some  surgeons,  though  the  majority  consider  it  injurious 
to  the  peritoneum,  and  therefore  prefer  the  administration 
of  water  by  the  rectum  or  subcutaneously. 

Flatulence. 

This  is  often  a  troublesome  complication  after  opera- 
tions, and  causes  the  patient  considerable  discomfort.  The 
following  is  an  excellent  prescription  for  the  relief  of  this 
condition  : 

^  Sal  volatile,  gi. 

Sodium  bicarbonate  (a  pinch). 
In  a  wineglassful  of  water. 

2 


1 8      The  After-Treatment  of  Operations 

This  generally  gives  immediate  relief.  A  few  drops  of 
peppermint  on  a  lump  of  sugar  or  soda-mint  tabloids  are 
also  very  useful.  The  best  way,  however,  of  relieving 
flatulence  is  to  open  the  bowels  by  administering  an 
aperient  or  to  give  a  turpentine  enema : 

]^  Turpentine  ....     gss. 

Gruel  .....     gxv. 

The  author  has  for  some  years  used  hypodermic  injec- 
tions*of  the  infundibular  portion  of  the  pituitary  gland  for 
this  purpose,  with  excellent  results.  One  cubic  centi- 
metre of  a  standard  preparation  of  this  drug  should  be 
injected  about  five  minutes  before  the  administration  of 
an  enema.  As  a  rule,  a  free  evacuation  of  wind  will  occur 
almost  immediately.  The  author  has  found  this  drug 
quite  invaluable  in  bad  cases  of  abdominal  distension. 
Eserine  is  another  drug  which  has  been  similarly  used. 

Bed-Sore. 

This  troublesome  complication  will  occasionally  arise 
in  spite  of  the  greatest  precautions.  It  is,  however, 
usually  a  preventable  complication,  and  should  not  occur 
when  proper  trained  nursing  is  obtainable.  The  question 
of  the  relation  of  the  position  of  the  patient  after  the 
operation  to  the  formation  of  bed-sores  has  already  been 
spoken  of  (p.  4).  Soiling  of  the  bedclothes,  due  to 
lack  of  proper  care  after  the  patient  has  micturated  or 
the  catheter  has  been  passed,  rucking  up  of  the  patient's 
nightdress  or  of  the  bedclothes,  are  all  frequent  and  easily 
preventable  causes  of  bed-sore.  By  far  the  most  potent 
cause  of  bed-sore  is  a  moist  condition  of  the  skin  where 
it  is  subjected  to  pressure,  and  the  greatest  care  should 
always  be  taken  to  keep  the  skin  as  dry  as  possible. 
After  a  bed-sore  has  formed,  the  part  must  be  relieved 


Introductory  19 

from  all  pressure,  either  by  turning  the  patient  into 
another  position  or  by  the  use  of  ring  air-cushions,  etc. 
The  sore  itself  must  be  kept  dry,  and  must  not  be  treated 
with  strong  or  irritating  antiseptics;  boracic  powder  or 
Fuller's  earth  are  the  best  applications  to  use,  but  they 
should  not  be  allowed  to  form  crusts  over  the  sore.  If 
much  sloughing  takes  place,  the  patient  must  be  turned 
over  upon  the  face  or  side  and  the  sore  dressed  frequently 
and  kept  as  clean  as  possible.  Dry  dressings  are  much 
preferable  to  wet  ones,  unless  it  is  desirable  to  hasten  the 
separation  of  the  slough,  when  the  following  dressing  will 
be  found  useful : 

^  Unguenti  sambuci  viridis    -  •  •     partes  ii. 

Unguenti  elemi        -  -  •  -         ,,      xvi. 

Copaib£e       --••»,,        Hi.* 

This  dressing  should  not  be  allowed  to  come  into  contact 
with  the  healthy  skin  round  the  sore. 

Painting  the  sore  over  with  Friar's  balsam  will  some- 
times hasten  the  healing  process.  If  there  is  much 
destruction  of  tissue,  Thiersch  grafting  should  be  em- 
ployed to  hasten  healing  and  prevent  scarring.  The 
sore  should  first  of  all  be  got  quite  clean,  .and  then  all  the 
granulation  tissue  should  be  scraped  away  and  the  grafts 
laid  on  the  underlying  fibrous  tissue  ;  the  dressing  should 
not  be  removed  for  at  least  a  week.  Thiersch  grafting, 
if  properly  done,  often  gives  most  excellent  results  in 
these  cases,  and  considerably  hastens  the  healing  process. 

The  worst  cases  of  bed-sore  are  those  which  occur  in 
pysemic  cases  and  cases  associated  with  some  spinal 
lesion  ;  in  many  of  these  cases  a  bed-sore  will  form  in 
spite  of  the  utmost  care. 

The  separation  of  the  slough  is  often  a  very  slow 
process  in  the  bad  cases,  and  it  is  sometimes  advisable  to 
*  St.  George's  Hospital  Pharmacopoeia. 


20     The  After-Treat  men  t  of  Operations 

hasten  it  by  occasionally  cutting  through  the  toughest 
bands  of  fibrous  tissue  with  a  pair  of  scissors,  care,  of 
course,  being  taken  not  to  cut  into  healthy  tissue. 
Hydrogen  peroxide  is  a  most  valuable  disinfectant  and 
antiseptic  to  use  in  these  sloughing  cases  ;  it  should  be 
painted  or  sprayed  on  frequently.  Sanitas  on  lint  is  also 
a  good  dressing. 

Post-Operative  Insanity  or  Mania. 

This  is  a  condition  which  is  but  seldom  met  with. 
It  does  not  seem  to  bear  any  definite  relation  to  the 
operation— that  is  to  say,  as  regards  cause  and  effect. 
The  symptoms  usually  first  show  themselves  during  con- 
valescence. The  onset  of  insanity  or  mania  is  probably 
to  be  attributed  to  the  mental  anxiety  and  morbid  brood- 
ing over  the  operation  by  a  mind  which  is  naturally 
unstable  rather  than  to  any  direct  effect  of  the  operation 
itself.  Sometimes  a  patient  who  is  the  subject  of  re-- 
curring  attacks  of  insanity  may  get  an  attack  after  an 
operation  ;  m  this  case  the  operation  acts  merely  as  an 
exciting  cause.  The  condition  is  more  often  seen  in 
women  than  men.  It  is  said  that  a  suicidal  tendency  is 
a  common  and  well-marked  feature  of  most  cases. 

Professor  Clifford  Allbutt  describes  the  condition  as 
one  of  neurasthenia  rather  than  of  insanity,  and  says  that 
a  certain  degree  of  it  more  commonly  follows  operations 
than  is  generally  supposed.  He  does  not,  however,  point 
out  why  this  should  be  the  case ;  and  it  is  possible  that  in 
some  of  these  cases  a  patient  of  a  particularly  morbid 
turn  of  mind  has  thought  herself  to  be  suflfering  from 
some  affection,  and  has  so  far  deceived  her  medical 
attendant  that  he  has  advised  operative  interference, 
which,  having  been  duly  carried  out,  has  subsequently 
been  ascribed  as  the  cause  of  her  mental  condition. 


Introductory  2 1 

Many  of  the  earlier  cases  of  acute  and  fatal  post- 
operative insanity  which  have  been  reported,  or  have 
found  their  way  into  the  literature  on  the  subject,  were 
in  all  probability  cases  of  acute  sepsis  or  cerebral  abscess 
resulting  from  the  operation,  and  were  therefore  not  in 
reality  insanity  at  all.  In  one  case  of  supposed  post- 
operative mania  which  came  under  the  observation  of  the 
writer,  it  was  discovered  at  the  post-mortem  examination 
that  there  was  a  large  abscess  in  the  brain. 

Under  the  name  post  -  operative  psychoses,  several 
forms  of  mental  derangement  have  been  described  which 
only  affect  the  intellectual  functions  ;  the  symptoms  are 
mainly  a  melancholic  type  of  insanity  commonly  accom- 
panied by  delusions. 

This  type  of  insanity  seems  to  be  most  common  after 
operations  upon  the  sexual  organs,  such  as  ovariotomy, 
hysterectomy,  removal  of  the  breast,  castration,  etc, 
and  after  operations  such  as  colotomy,  gastrostomy, 
etc.,  the  results  of  which  constantly  remind  the  patient 
of  his,  or  her,  diseased  condition.  It  has  been  pointed  out 
that  operations  upon  persons  of  a  highly-strung  and 
nervous  temperament  may  occasionally  be  followed  by  a 
complete  nervous  breakdown  and  general  neurasthenia, 
which  may  persist  for  a  considerable  time,  and  thus 
greatly  delay  recovery.  Dr.  Burr  quotes  a  case  where 
a  young  man  of  highly  nervous  temperament,  but  whose 
previous  health  had  been  good,  was  attacked  by  appendi- 
citis and  operated  upon.  After  the  operation  he  made, 
from  a  surgical  point  of  view,  a  good  recovery  ;  but  he 
remained  prostrate  in  bed,  unable  to  do  anything  from 
complete  nervous  breakdown,  and  it  was  some  months 
before  he  was  well  again. 

Before  operating  upon  all  such  patients  the  greatest 
care  should  be  taken  to  prepare  them  properly  for  the 


2  2     The  After-Treatment  of  Operations 

operation.  An  attempt  should  be  made  to  get  them  into 
a  better  mental  condition  by  careful  attention  to  the 
general  nutrition  and  hygiene,  and  they  should  be  given, 
as  far  as  possible,  a  complete  rest  in  both  body  and  mind, 
so  as  to  get  them  into  a  normal  mental  condition  before 
performing  the  operation.  There  can  be  no  doubt  that 
in  the  careful  preparation  of  the  patient  beforehand  lies 
the  chief  safeguard  against  post -operative  mental  con- 
ditions. 

In  examining  the  recorded  cases  where  mania  has 
followed  an  operation,  it  is  noticeable  that  in  a  large 
number  of  the  cases  the  wound  was  septic.  This 
suggests  that  the  mania  might  have  been  due  to  septic 
poisoning  rather  than  to  any  mental  change  in  the 
patient  produced  directly  by  the  operation,  and  that 
such  cases  should  really  be  looked  upon  as  delirium, 
similar  to  that  which  may  occur  in  the  course  of  any 
acute  infection. 

A  well-marked  group  of  cases  are  those  where  delirium 
tremens  follows  an  operation  upon  an  alcoholic  subject. 
I  think  that  in  these  cases  the  partial  starvation  or 
alteration  in  diet  necessitated  by  the  operation  is  more 
often  the  cause  of  the  delirium  than  the  actual  operation 
itself.  When  an  alcoholic  patient  has  to  be  operated 
upon,  the  best  way  of  preventing  the  occurrence  of 
delirium  is  to  first  accustom  the  patient  to  a  reduced 
and  altered  diet,  and  to  the  change  in  conditions  which 
the  operation  necessitates. 

Dr.  Savage  has  recorded  a  large  number  of  cases 
which  seem  to  show  that  the  anaesthetic  alone  may  be 
the  cause  of  mental  disturbance  in  some  cases.  The 
use  of  iodoform  in  the  wound  has  also  been  considered 
as  the  cause  by  some  writers. 

As  regards  the  important  subject  of  prognosis^  the  late 


Introducto 


vy  23 


Mr.  Clinton  Dent,  who  collected  a  large  number  of  cases, 
came  to  the  following  conclusions  : 

The  prognosis  is  most  grave  when  acute  mania  occurs 
shortly  after  a  serious  operation,  although  the  purely 
surgical  aspect  of  the  case  may  be  favourable.  The 
more  chronic  the  mania  the  better  is  the  prognosis  so 
far  as  life  is  concerned. 

In  ordinary  insanity  the  prognosis  is  favourable  if  the 
patient  gains  weight  and  strength. 

Illustrative  Case.  —  Sarah  C,  married,  aged  forty -eight,  was 
admitted  to  St.  George's  Hospital.  She  had  had  eight  children,  of 
whom  six  were  alive  and  well,  and  the  youngest  six  years  old. 
She  had  always  lived  in  the  country,  was  of  healthy  appearance,  of 
slightly  reserved  manner.  Absolutely  no  history,  even  remote,  of 
hereditary  disease,  and  no  trace  of  insanity  in  her  family. 

Four  years  previously  she  had  noticed  a  small  swelling  in  the 
abdomen  on  the  left  side ;  this  increased  rapidly  up  to  a  certain 
point,  and  then  appeared  to  remain  stationary. 

Ovariotomy  was  performed.  The  tumour  consisted  of  one  large 
cyst  and  several  smaller  cysts.  Ether  was  given.  The  progress  of 
the  case  subsequently  for  the  first  six  days  was  satisfactory  enough; 
she  was  cheerful,  anxious  to  get  well,  and  slept  and  ate  normally. 
On  the  sixth  day  her  physical  condition  was  satisfactory,  but  her 
expression  had  entirely  altered.  She  still  recognised  her  husband 
and  those  who  were  immediately  concerned  with  her  care,  but  her 
mind  was  full  of  delusions,  varying  in  their  nature,  but  all,  to  her, 
of  an  alarming  character.  She  was  very  restless  in  bed.  On  the 
eighth  day  she  was  in  a  condition  of  acute  mania.  She  recognised 
no  one,  attempted  to  injure  those  about  her,  and  was  very  violent. 
The  hair  became  coarse  and  rough.  There  was  a  little  superficial 
suppuration  in  the  wound,  where  she  had  torn  the  edges  apart  in 
her  struggles,  but  in  all  other  respects,  so  far  as  the  immediate 
operation  was  concerned,  everything  was  perfectly  satisfactory. 
During  the  next  eight-and  forty  hours  the  mania  continued  with 
undiminished  intensity.  Her  physical  condition  became  weaker, 
and  the  greatest  difficulty  was  experienced  in  getting  her  to  take 
any  food.  She  died  exhausted  on  the  eleventh  day.  No  iodoform 
was  used,  nor  carbolic  acid ;  no  peritonitis  was  found,  nor,  indeed, 
anything  in  the  abdomen  worthy  of  note,  at  the  post-mortem 
examination. 


24     The  After-Treatment  of  Operations 

Illustrative  Case. — E.  H.,  an  unmarried  woman,  aged  thirty-one, 
had  been  suffering  for  some  months  from  rectal  haemorrhage,  and 
on  examination  this  was  found  to  be  due  to  cancer  of  the  bowel- 
She  was  of  rather  a  nervous  and  excitable  temperament,  and  was 
just  about  to  be  married  at  the  time  of  this  distressing  discovery- 
She  was  not  informed  of  the  nature  of  the  trouble,  but  was  told 
that  an  operation  was  necessary.  The  operation  was  agreed  to, 
and  I  removed  the  rectum  and  growth,  and  was  able  to  bring  down 
the  sigmoid  and  restore  the  normal  anal  opening.  The  result  was 
extremely  satisfactory,  and  the  wound  healed  by  first  intention 
without  any  rise  of  temperature.  She  was  able  to  return  home  in 
three  weeks,  and  in  a  short  time  regained  the  normal  use  of  her 
bowels.  The  result  from  a  surgical  point  of  view  was  excellent, 
and  the  patient  appeared  contented  and  most  reasonable.  But 
about  four  months  later  she  began  to  show  signs  of  severe  melan- 
cholia, and  in  spite  of  the  fact  that  she  suffered  no  inconvenience 
as  the  result  of  the  operation,  beyond  the  necessity  of  occasionally 
using  an  enema,  she  developed  suicidal  tendencies,  and  became  so 
unmanageable  that  she  had  to  be  confined  in  an  asylum.  Her 
mental  symptoms  gradually  improved  after  this,  and  she  made  a 
complete  recovery.  A  year  and  a  half  after  the  operation  she  was 
quite  well,  and  six  months  later  she  got  married. 


REFERENCES. 


Picque  and  Briand:  Archives  de  Neurologic,  March,  1903. 

'  Unusual  Forms  of  Nervous  Prostration   following  Operations ' : 

Lancet,  May  17,  1902,  p.  1415. 
'  Paralyses    and    Psychoses    following    Prolonged    Anaesthesia ' : 

Lancet,  June  3,  1899,  p.  1508. 
Article  by  Dr.  C.  Burr,  Philadelphia  Medical  Journal,  April  19,  1902. 
'  Insanity  following  Surgical  Operations  '  :  C.  T.  Dent,  Journal  0/ 

Mental  Science,  April,  1889. 


CHAPTER  II 
TREATMENT  OF  THE  WOUND 

In  these  days  the  vast  majority  of  wounds  are  aseptic  and 
run  an  aseptic  course,  and  it  is  not  necessary  or  even 
advisable  to  change  the  dressings  often.  From  one  cause 
and  another,  however,  suppuration  will  sometimes  take 
place,  and  it  is  therefore  a  matter  of  considerable  im- 
portance to  detect  the  presence  of  suppuration  when  it 
does  occur  at  the  earliest  possible  date,  so  that  it  may 
be  promptly  dealt  with  ;  and  not  to  discover,  perhaps  at 
the  end  of  a  week,  on  removing  the  dressings,  that  the 
wound  has  all  broken  down  and  the  dressings  are  soaked 
with  discharge.  The  temperature  chart,  if  properly  inter- 
preted, is  a  most  valuable  guide  to  the  condition  of  the 
wound,  and  a  chart  of  the  temperature  should  always  be 
kept  after  any  operation. 

It  is  important  to  remember  that  a  rise  of  temperature 
during  the  first  thirty-six  or  even  forty-eight  hours  is  the 
rule  after  an  operation  of  any  magnitude.  On  examining 
a  hundred  consecutive  cases  after  operation  in  the  wards 
of  St.  George's  Hospital,  in  all  of  which  the  wound  ran 
a  perfectly  aseptic  course,  the  writer  found  that  a  rise  of 
temperature  occurred  in  85  per  cent,  within  the  first  forty- 
eight  hours.  The  following  table  will  show  the  results 
of  this  investigation : 

25 


26     The  After-Treatment  of  Operations 


Table  of  the  Temperatures  during  the  first  Forty- 
eight  Hours  of  ioo  Consecutive  Cases  of  Opera- 
tion   IN    WHICH    THE    WoUND    REMAINED    ASEPTIC. 

Per  Cent. 
There   was   a  rise   of   temperature   to   or   above 

ioo°  F.  in   . .              . .              . .              . .              • •  27 

There  was  a  rise  to  or  above  99°  F.  in    . .             . .  46 

There  was  a  rise  above  normal,  but  below  99°  F.  in  12 
The  temperature  remained  normal  or  fell  below  it 

in..            ..            ..            ..            ..             ••  15 


lOf 

y. 

'*j 

10  tf 

■s. 

9S 

3(f 

J 

^ 

^ 

^~ 

t 

- 

k 

h/ 

te- 

- 

fy-y' 

\ 

8? 

C3 
02° 
101° 
100" 
99" 
96° 
9? 

§i 

J- 

^ 

i.^ 

0^ 

^ 

K 

Sn 

^- 

- 

-- 

V 

- 

■»• 

^ 

♦ 

^ 

•: 

Fig.  5.  —  Radical 
CURE  OF  Hernia 
(Aseptic). 


Fig.  6. — ^Amputation  of 
THE  Thigh  (Aseptic), 

This  shows  the  double  rise. 


It  is  further  noticeable  that  in 
children  this  rise  of  temperature  is 
often  much  more  marked  than  in 
adults ;  the  high  temperature  is  often 
a  morning  one,  and  is  followed  by  an 
evening  drop.  The  rise  in  children 
may  be  very  high  sometimes,  and  in 
the  above  100  cases  one  child  had  a 
temperature  of  104-5°  (^ig-  9)'  though 
there  was  no  cause  discoverable  beyond 
the  operation.  After  operations  in- 
volving  interference  with   bone,   it   is 


^ 

101° 

0; 

(J. 

f 

99 

0: 

J 

\ 

^- 

\j 

P 

<•< 

A 

97° 

6 

Fig.  7.  —  Ampu- 
tation OF  the 
Breast  (Asep- 
tic). 


Treatment  of  the  Wound 


27 


remarkable   that    the   post -operative    pyrexia   is    often 
high  ;    the    operation    for    the    Hgature    of    piles    also 


KM 

^ 

1 

101° 

0. 

f 

93° 

98° 
87° 

/ 

i 

-- 

4- 

'^ 

gs 

^8 

KM 

C3 
102° 
101° 
100° 
99" 
98° 
S7 

fi 

0: 

u 

i 

K 

0: 

I 

\ 

h 

^ 

•^ 

\ 

4 

/ 

- 

-- 

-\- 

- 

V 

> 

W 

•- 

« 

Fig.  8. — Operation 
FOR  Hare-Lip  on 
A  Child  Five 
Months  Old. 


Fig.  9.  —  Laparotomy 
FOR  Intussusception 
ON  A  Child  aged  Two 
Years  (Aseptic). 


seems  often  to  result  in  an  exceptionally  high  tem- 
perature (Fig.  10).  It  was  found  in  the  investigation 
of  the  above  100  cases  that  a  second  slight  rise  in 
the  temperature  not  uncommonly  fol- 
lowed the  first  (see  Fig.  6). 

This  rise  of  temperature  is  probably 
due  to  reaction,  and  is  what  the  text- 
books describe  as  aseptic  fever.  There 
is  generally  a  preliminary  drop  to  a 
subnormal  temperature  immediately 
after  the  operation,  followed  by  re- 
action and  a  rise  to  about  99°  or  100° 
(Fig.  5),  In  some  cases,  and  especially 
in  children  and  young  adults,  the  rise 
is  considerably  higher  ;  this  would 
naturally  be  expected,  as  young 
patients     always     react     much     more 


\^ 

■^ 

H 

0 

J 

1 

99' 

f 

I 

^ 

^ 

- 

- 

- 

^ 

=&■ 

^ 

Fig.  10. — Opera- 
tion FOR  Piles 
BY  Ligature 
(Aseptic). 


28     The  After-Treatment  of  Operations 

violently  than  older  ones.  Again,  in  the  case  of  patients 
who  are  in  exceptionally  good  general  health  at  the  time 
of  the  operation,  the  reaction  and  consequent  tempera- 
ture is  often  high.  The  rise  of  temperature  usually  takes 
place  on  the  first  night  after  the  operation,  sometimes  on 
the  second.  This  rise  of  temperature  is  a  good  sign,  as 
it  shows  reaction,  and  is  very  much  better  than  a  drop  to 
a  subnormal  temperature  which  persists.  This  post- 
operative temperature  or  aseptic  fever  should  therefore 


■_ 

> 

O. 

fi 

'j 

100° 

1 

'  f 

I 

^ 

Q 

■ 

/ 

^ 

I 

<v 

H' 

- 

t  . 

r 

^ 

rfr- 

i 

-- 

—  ^- 

\ 

f 

v 

"il 

86^ 

:• 

\t\ 

; 

Fig.  II. — Operation  on  the 
Knee-Joint  (Septic). 


Fig.  12.  — Operation  for 
Radical  Cure  of  Hernia 
(Septic).* 


be  expected,  and  must  not  be  confused  with  a  tempera- 
ture due  to  sepsis  ;  it  usually  falls  again  at  once,  and  the 
subsequent  temperature  is  normal.  After  very  severe 
operations  involving  much  shock,  this  post-operative 
temperature,  as  one  would  expect,  is  often  delayed  until 
the  shock  has  passed  off. 

The  above  was  written  in  1903,  before  the  use  of 
rubber  gloves  and  masks  became  the  usual  practice,  and 
some  modification  of  these  views  is  now  necessary.  It 
has  been  decided,  however,  to  let  the  passage  stand,  as  it  is 

*  There  was  pus  in  the  wound  on  the  fourth  day. 


Treatment  of  the  Wound  29 

essentially  correct,  although  by  the  use  of  the  present 
surgical  technique  the  reactionary  temperature  is  often 
abolished,  and  no  alteration  of  temperature  occurs.  In 
other  words,  the  high  reactionary  temperature  then  seen 
in  the  healing  process  of  wounds  which  healed  by  first 
intention  was  sometimes  due  to  the  reaction  against 
micro-organisms  introduced  into  the  wound,  but  which 
the  tissues  dealt  with  successfully.  Blood-clot  in  a 
wound  will,  however,  often  give  rise  to  a  sharp  reaction- 
ary temperature,  quite  apart  from  septic  infection. 

When  the  wound  is  septic,  this  preliminary  rise  in 
temperature  is  not  followed  by  a  drop,  but  persists,  often  to 
become  intermittent  later  on  (Fig.  11);  or  the  preliminary 
rise  is  absent,  being  replaced  by  a  slightly  subnormal 
temperature  for  the  first  two  or  three  days,  and  is  then  fol- 
lowed by  a  rise  to  102°  (Fig.  12)  or  higher.  In  most  cases 
when  the  wound  has  become  septic  the  temperature  rises 
on  the  evening  of  the  second  or  third  day,  and  sometimes 
as  late  as  the  fifth  or  sixth  day  after  the  operation.  So  that 
a  rise  of  temperature  during  the  first  forty-eight  hours, 
unless  accompanied  by  other  local  or  general  signs  of 
sepsis  or  unless  it  remain  up,  need  not  be  looked  upon  as 
evidence  of  sepsis,  but,  on  the  other  hand,  as  a  favourable 
sign  ;  persistence  of  this  temperature,  however,  especially 
in  the  morning,  or  a  rise  occurring  after  the  second  day 
following  the  operation,  is  to  be  looked  upon  as  evidence 
of  sepsis,  and  should  be  followed  at  once  by  an  examina- 
tion of  the  wound.  Unfortunately,  in  a  certain  number 
of  cases  the  chart  shows  a  perfectly  normal  temperature, 
except,  perhaps,  for  the  reactionary  rise  ;  and  yet  when  the 
wound  is  examined  some  days  after  the  operation,  it  is 
found  to  have  broken  down  and  contain  pus.  These  are 
mostly  cases  where  blood-clot  has  been  left  in  the  wound, 
and  some  comparatively  non-pathogenic  organism,  such 


30     The  After-Treatment  of  Operations 

as  Staphylococcus  pyogenes  alius  or  citreus  or  the  Bacillus 
epidermidis,  has  obtained  access  to  it  and  converted  it 
into  pus.  When  a  wound  that  has  apparently  healed 
breaks  down  ten  days  or  a  fortnight  after  the  operation, 
it  is  generally  due  to  infected  catgut  used  for  buried 
sutures,  sepsis  commencing  at  the  time  when  the  sutures 
begin  to  dissolve. 

In  such  cases  there  is  usually  but  little  local  inflamma- 
tion in  the  wound,  but  a  cavity  is  found  containing  pus 
which  originally  contained  blood-clot.  The  condition 
does  not,  as  a  rule,  cause  any  temperature  or  pain, 
though  the  patient  may  sometimes  complain  of  dis- 
comfort at  the  site  of  the  wound.  Fortunately,  this 
condition  is  not  of  very  serious  import,  and  such  wounds 
heal  very  rapidly  after  the  removal  of  the  pus,  providing 
that  care  be  taken  to  prevent  the  wound  becoming 
subsequently  infected  by  some  more  virulent  organism. 
Pain  referred  to  the  site  of  the  wound,  if  it  continues,  is 
often  a  sign  of  inflammation  and  sepsis.  After  the  first 
twenty-four  hours  an  aseptic  wound,  unless  it  be  in 
some  special  situation,  is,  as  a  rule,  painless. 

At  the  present  time,  with  the  best  technique,  infection 
of  surgical  wounds,  unless  infection  is  present  at  the  time 
of  operation,  should  be  a  very  rare  occurrence.  Many 
surgeons  have  reduced  their  proportion  of  cases  in  which 
infection  of  the  wound  takes  place  to  fractions  of  i  per 
cent. ;  and  any  surgeon  who  finds  infection  occurring  in 
even  i  per  cent,  of  his  cases  should  seriously  revise  his 
methods.  The  latest  figures  published  from  the  Mayo 
clinic  are  117  cases  of  infection  in  6,825  cases,  or  o'oiy 
per  cent,  (Surgery,  Gynecol.,  and  ObsteL,  May,  1914). 


Treatment  of  the  Wound  31 

Aseptic  Wounds. 

I.  Where  the  Dressings  have  not  been  soaked 
THROUGH  BY  OoziNG. — Unless  the  dressings  have  become 
loose  or  soiled,  the  wound  need  not  be  dressed  until  the 
time  has  come  for  the  removal  of  the  stitches.  The 
time  at  which  the  stitches  should  be  removed  varies 
considerably  in  different  cases.  In  moderately  small 
wounds  they  should,  as  a  rule,  be  removed  about  the 
sixth  or  seventh  day  after  the  operation.  In  wounds  on 
the  face  or  neck  they  may  be  removed  earlier,  as  healing 
in  this  situation  is  rapid,  and  it  is  particularly  desirable 
to  avoid  scarring ;  they  should  be  removed  about  the 
second  or  third  day.  In  the  case  of  large  wounds,  or 
wounds  the  edges  of  which  are  subject  to  tension,  the 
stitches  should  be  left  for  ten  days  or  a  fortnight.  It  is 
also  advisable  to  leave  the  stitches  somewhat  longer 
when  the  skin  round  the  wound  is  not  well  nourished,  as 
is  often  the  case  in  wounds  for  the  removal  of  varicose 
veins  of  the  leg. 

Some  surgeons  habitually  dress  all  wounds  on  the 
second  or  third  day  after  the  operation.  This,  however, 
seems  unnecessary  and  inadvisable  in  the  majority  of 
cases.  Usually  a  certain  amount  of  blood  oozes  from 
the  wound  immediately  after  the  dressings  are  applied. 
This  soaks  into  the  dressings,  and,  hardening,  sticks 
them  to  the  wound  and  surrounding  skin,  thus  forming 
a  sort  of  splint  to  the  wound,  which  acts  very  beneficially 
in  keeping  it  and  the  surrounding  skin  at  rest.  Of 
course,  when  this  oozing  has  come  to  the  edge  of  the 
dressings,  and  has  come  in  contact  with  the  air,  it  should 
at  once  be  changed,  as  otherwise  it  may  act  as  a  tract  for 
the  entrance  of  septic  organisms. 

A    pair    of    scissors    and   forceps  which    have   been 


32     The  After-Treatment  of  Operations 

sterilized  by  boiling  should  be  at  hand  in  a  tray  contain- 
ing carbolic  lotion.  The  bandages  should  then  be  cut 
through  with  a  different  pair  of  scissors,  and  removed, 
together  with  the  cotton-wool,  so  that  the  wound 
remains  covered  only  with  the  gauze.  A  warm  towel 
which  has  been  previously  sterilized,  either  by  boiling  or 
immersion  for  some  time  in  carbolic  lotion,  should  then 
be  placed  round  the  gauze  covering  the  wound.  The 
surgeon  should  then  clean  his  hands  in  the  ordinary  way, 
by  first  scrubbing  them  with  soap  and  water,  and  then 
immersing  them  for  a  minute  or  two  in  some  antiseptic 
solution,  preferably  an  alcoholic  solution  of  biniodide  of 
mercury  (i  in  i,ooo).  The  gauze  should  next  be  removed 
from  the  wound.  If  it  is  much  stuck,  it  is  best  to  soak 
it  well  with  some  lotion  before  removing  it.  As  soon  as 
the  gauze  is  removed  the  wound  should  be  covered  with 
a  swab  or  a  piece  of  gauze,  and  the  skin  round  swabbed 
over  with  lotion  to  clean  it.  If  the  wound  appears  to  be 
healed,  which  will  probably  be  the  case,  the  stitches 
should  be  removet^. 

The  skin  is  now  often  prepared  before  operation  by 
using  iodine,  which  is  painted  over  the  wound  area ;  and 
in  this  case,  when  the  dressings  are  changed  or  the  stitches 
are  to  be  removed,  the  wound  should  be  again  painted 
over  with  the  iodine  solution.  When  iodine  solution  is 
used,  the  skin  round  the  wound  should  not  be  made  wet 
with  a  watery  lotion,  as  this  interferes  with  the  action  of 
the  alcoholic  iodine  solution. 

Removal  of  Stitches. — This  is  best  done  with  a  pair  of 
blunt-pointed  scissors  which  cut  well  at  the  points.  All 
the  stitches  should  be  divided  first  before  any  of  them  are 
removed.  The  scissors  should  be  used  on  the  flat,  one 
blade  being  inserted  below  the  stitch,  and  then  the  latter 
cut  as  close  as  possible  to  the  skin  surface.     The  forceps 


Treatment  of  the  Wound  33 

should  be  used  to  steady  or  lift  the  stitch  if  necessary. 
After  all  the  stitches  have  been  cut  they  may  be  removed 
by  pulling  on  one  end  with  the  forceps.  If  the  stitches 
are  not  cut  through  close  to  the  skin  an  elbow  or  kink 
will  probably  be  left  in  the  stitch  which  will  cause  pain 
when  it  is  drawn  out  through  the  stitch- tract.  This 
applies  especially  to  stiff  sutures,  such  as  fish-gut.  If 
the  stitches  are  removed  in  this  way,  very  little  pain  will 
be  caused,  and  with  a  nervous  patient  this  is  a  point  of 
some  importance.  When  the  stitches  have  become 
buried  in  the  skin,  as  is  often  the  case  in  abdominal 
wounds,  especially  in  fat  people,  the  cut  ends  of  the 
suture,  which  can  always  be  seen,  should  be  pulled  on 
with  forceps  until  the  knot  comes  into  view ;  then  the 
points  of  the  scissors  (held  on  the  flat)  must  be  passed 
down  behind  the  knot,  and  the  suture  divided  and  with- 
drawn. It  is  often  advisable  not  to  remove  all  the 
stitches  at  one  time,  but  to  leave  a  few  till  a  later  date. 
If  after  removal  of  the  stitches  the  wound  is  found  to  be 
dry  and  does  not  gape,  it  may  be  sealed  up  by  placing 
over  it  a  piece  of  dry  gauze  cut  to  the  required  shape, 
and  painting  over  the  whole  with  flexible  collodion.  A 
large  pad  of  cotton-wool  is  then  placed  over  it  and  the 
bandage  applied,  or  the  latter  may  be  dispensed  with 
altogether  if  the  wound  is  a  small  one.  Should  there  be 
any  gaping  or  other  reason  rendering  it  undesirable  to 
seal  the  wound,  it  may  either  be  redressed  as  before  with 
wet  gauze,  or  powdered  over  with  boracic  acid  powder 
or  dermatol,  etc.,  and  covered  with  dry  gauze  and  cotton- 
wool. When  there  is  much  gaping  of  the  wound  after 
removal  of  the  stitches,  the  edges  should  be  drawn 
together  with  strapping.  The  so-called  American  or 
Mead's  strapping  should  be  used  for  this  purpose,  and  the 

part  crossing  the  wound  should  be  cut  very  narrow.     A 

3 


34     The  After-Treatment  of  Operations 

good  plan  of  cutting  the  strapping  is  shown  in  the  illus- 
tration (Fig.  13).  Two  pieces,  AB  and  CD,  are  cut  of  the 
shape  shown  ;  the  part  C  is  fixed  to  the  skin  on  one  side 
of  the  wound,  and  the  part  B  on  the  other.  The  part  A 
is  then  passed  through  the  gap  in  CD,  and  D  and  A  are 
pulled  upon  in  opposite  directions  until  the  gap  is  closed 
and  the  edges  of  the  wound  well  approximated  ;  they  are 
then  stuck  down. 


Fig.  13. 

2.  Where  the  Dressings  have  been  soaked 
THROUGH. — When  blood  from  the  wound  has  soaked 
through  the  dressings  and  stained  the  bandages,  the 
wound  should  at  once  be  dressed.  This  should  be  done 
in  the  same  way  and  with  even  more  care  than  in  the 
case  of  a  wound  which  is  not  dressed  until  the  stitches 
are  removed.  Even  if  only  a  little  blood  has  soaked 
through  at  one  part  of  the  dressings  it  is  better  to  change 
them,  as  otherwise  the  blood  which  has  soaked  into  the 
dressings  may  act  as  a  tract  for  the  entrance  of  organisms 
to  the  wound. 

3.  Where  Drainage  has  been  provided  for  by  a 
Tube  or  Gauze  Plugging  at  the  Operation. — As  a 
rule,  it  is  better  to  remove  the  tube  at  the  end  of  twenty- 
four  or  forty-eight  hours.  This  will,  however,  depend 
a  good  deal  on  the  reasons  for  which  the  tube  was  used. 
It  is  not  desirable  to  leave  a  tube  in  an  aseptic  wound 


Treatment  of  the  Wound  35 

longer  than  is  absolutely  necessary,  as  a  very  unsightly 
scar  with  inverted  edges  is  apt  to  result,  and  the  healing 
of  the  wound  is  delayed.  Also  there  is  seldom  any 
necessity  for  the  use  of  a  tube  after  the  first  twenty-four 
hours.  A  very  good  plan  is  to  pass  a  stitch  through  the 
skin  on  each  side  of  the  tube  and  to  leave  the  ends 
untied.  The  stitch  can  then  be  tied  up  after  the  tube  has 
been  removed.  Great  care  should  be  taken  in  dressing 
these  wounds,  as  there  is  of  necessity  an  open  tract  into 
the  depths  of  the  wound,  and  healing  is  at  a  stage  when 
infection  can  readily  take  place.  Special  care  should  be 
taken  to  clean  up  the  skin  round  the  wound  with  anti- 
septic lotion  and  swabs.  This  should  be  done  from  the 
wound,  and  not  towards  it.  Thus  a  swab  which  has 
been  used  for  cleaning  the  outlying  areas  of  the  skin 
must  not  subsequently  be  placed  in  contact  with  the 
wound.  The  dressing  should  be  carried  out  in  the  same 
way  as  before,  except  that  the  wound  should  not  be 
sealed  up  with  collodion,  and  it  is  best  not  to  apply 
any  of  the  antiseptic  powders,  as  they  are  often  not 
sterile. 

In  many  operations,  notably  in  abdominal  section  for 
localized  peritonitis  and  operations  for  necrosis  or  abscess 
of  bone,  it  used  to  be  a  common  practice  for  the  cavity 
to  be  left  plugged  with  gauze,  the  end  of  the  gauze  being 
left  protruding  from  the  wound  so  as  to  act  as  a  drain. 
When  a  large  cavity  in  the  abdomen  has  been  plugged  in 
this  way,  it  is  often  rather  difficult  to  remove  the  plug 
without  causing  the  patient  a  considerable  amount  of 
pain.  The  best  plan  is  to  leave  the  plug  in  for  five  or  six 
days  or  even  longer  until  it  has  become  loosened ;  it  will 
then,  as  a  rule,  be  found  to  come  away  quite  easily. 
While  the  gauze  is  being  removed  it  should  be  wetted 
from  time  to  time  with  some  suitable  antiseptic  lotion, 


36     The  After-Treatment  of  Operations 

or  with  peroxide  of  hydrogen,  5  volumes  per  cent.,  as  it 
is  much  more  easily  removed  when  it  is  wet  than  in  a 
half-dried  condition.  It  should  be  drawn  upon  first  from 
one  side  and  then  from  the  other,  and  considerable 
patience  is  often  necessary  in  order  to  avoid  hurting  the 
patient.  In  cases  of  acute  necrosis  of  bone,  etc^  when 
a  cavity  in  the  bone  has  been  packed  with  gauze,  it  is  not 
advisable  to  wait  until  the  gauze  has  become  loose,  and 
the  packing  should  be  removed  in  twenty-four  or  forty- 
eight  hours  ;  as  this  is  frequently  a  very  painful  proceed- 
ing, an  anaesthetic  should  be  administered.  Nitrous 
oxide  is  quite  sufficient  for  this  purpose,  and  under  its 
influence  the  gauze  can  be  quickly  removed,  and  the 
cavity,  if  necessary,  repacked.  This  practice  of  plugging 
wounds  with  gauze  is  now  practically  obsolete,  cavities 
being  simply  drained  with  tubes  or  left  open. 

4.  When  the  Wound  has  become  Septic — When 
from  the  condition  of  the  patient's  temperature  or  from 
some  other  indication  it  is  suspected  that  the  wound  has 
become  septic,  it  should  at  once  be  dressed,  the  same 
care  being  exercised  as  if  dealing  with  an  aseptic  wound. 
It  is  sometimes  thought  that  it  is  not  necessary  to  take 
the  same  aseptic  precautions  in  dressing  a  septic  wound 
as  with  one  which  is  aseptic.  This  is  quite  erroneous. 
Sepsis  may  result  from  many  different  kinds  of  organisms 
of  varying  pathogenicity  and  virulence,  and  if  the  wound 
is  carelessly  dressed  fresh  organisms  may  get  in,  which 
will  find  a  congenial  soil  in  the  already  septic  wound, 
and  a  much  more  serious  type  of  sepsis  may  be  the 
result. 

The  wound  having  been  exposed  and  found  to  be 
inflamed  and  septic,  a  sufficient  number  of  stitches 
should  be  cut  through  to  allow  a  free  exit  to  the  pus  and 
to  relieve  all  the  tension  on  the  tissues.     This  is  a  very 


Treatment  of  the  Wound  37 

important  point,  as  if  the  pus  is  subjected  to  tension  in 
any  part  of  the  wound  it  will  be  much  more  liable  to  find 
its  way  into  the  lymphatics  and  veins,  or  to  push  its  way 
along  the  planes  of  cellular  tissue,  than  will  be  the  case 
if  it  is  given  a  free  exit  through  the  skin.  All  pus  should 
be  removed  from  the  wound,  and  the  wound  itself  dried 
out  with  swabs  or  sponges.  Opinion  differs  a  good  deal 
as  to  whether  during  the  acute  stage  of  the  inflammation 
the  wound  should  be  irrigated  with  some  antiseptic  lotion 
or  not.  The  chief  objection  to  the  irrigation  of  the 
wound  with  strong  antiseptic  solutions  is  that  the  anti- 
septic irritates  the  already  inflamed  and  injured  tissues, 
and  is  liable  to  break  down  the  delicate  lymph  barrier 
which  has  probably  formed  between  the  pus  and  the 
lymphatics,  so  allowing  organisms  which  before  were 
only  local  to  gain  an  entrance  to  the  general  circulation  ; 
while,  on  the  other  hand,  washing  out  the  wound  with  an 
antiseptic  will  not  destroy  all  the  organisms  in  the  tissues 
surrounding  the  wound,  and  therefore  cannot  arrest  the 
septic  process.  It  is  to  the  tissues  themselves  that  we 
have  to  look  for  an  arrest  of  the  condition,  and  care 
should  therefore  be  taken  to  avoid  injuring  them.  There 
cannot,  however,  be  any  objection  to  gently  irrigating 
the  wound  with  normal  salt  solution  or  with  some  weak 
antiseptic,  so  as  to  wash  away  as  much  as  possible  of  the 
pus  and  infective  material  present  in  the  wound.  Saline 
solution  previously  sterilized  is  undoubtedly  the  best  fluid 
for  this  purpose,  though  a  weak  solution  of  carbolic  or 
biniodide  may  be  used  if  this  is  not  at  hand. 

In  cases  of  very  severe  sepsis,  where  the  tissues  show 
little  reactive  power  and  there  is  evidence  of  general 
infection,  such  as  the  enlargement  of  the  neighbouring 
lymphatic  glands,  lymphangitis,  or  the  presence  of  severe 
general  symptoms,  an  attempt  may  sometimes  be  made 


38     The  After-Treatment  of  Operations 

to  destroy  as  far  as  possible  the  organisms  present  at  the 
source  of  infection,  with  the  hope  of  so  preventing  any 
further  absorption  of  their  toxic  products.  To  carry  this 
out  the  wound  should  be  freely  opened  up,  and  well 
swabbed  out  with  some  powerful  antiseptic^  such  as 
I  in  20  carbolic  acid  or  i  in  500  biniodide.  Unfortu- 
nately, almost  all  the  present  antiseptics  in  use  coagulate 
albumen,  and  when  used  in  this  way  a  thin  coagulum  is 
formed  over  the  surface  of  the  tissues,  so  that  the  action 
of  the  antiseptic  is  limited,  as  a  rule,  to  the  superficial 
parts  of  the  wound.  This  method  of  dealing  with  septic 
wounds  is  not  a  safe  one  to  use  when  the  wound  has  an 
extensive  surface,  especially  in  children  or  old  people,  as 
under  such  circumstances  it  may  be  followed  by  symptoms 
of  poisoning  by  the  drug  used.  Drainage-tubes  should 
be  inserted  into  all  the  pockets  of  the  wound,  and  steps 
taken  to  keep  the  wound  open  by  packing  it  lightly  with 
gauze.  If  there  is  much  local  inflammation,  hot  fomenta- 
tions may  be  made  use  of  with  advantage.  For  this 
purpose  the  ordinary  boracic  fomentation  is  very  unsuit- 
able, as  it  only  remains  hot  for  a  very  short  time,  and  has 
very  slight  absorbent  properties,  not  to  speak  of  the  fact 
that  its  antiseptic  power  is  practically  nil.  Most  of  the 
ordinary  septic  organisms  can  be  grown  upon  it  with 
ease.  A  very  good  fomentation  can  be  made  by  using  a 
thick  layer  of  gauze  wrung  out  in  a  towel  after  it  has 
been  well  soaked  in  a  hot  solution  of  i  in  100  carbolic 
acid  ;  the  carbolic,  besides  insuring  the  asepticity  of  the 
fomentation,  acts  as  a  local  anaesthetic  and  reduces  the 
pain. 

Gauze  is  one  of  the  most  absorbent  dressings  we 
possess,  and  it  is  very  important  to  use  a  dressing  that 
will  quickly  soak  up  all  the  discharge  from  the  wound. 
Gauze  is,  unfortunately,  rather  expensive,  but  plain  un- 


Treatment  of  the  Wound  .39 

medicated  gauze  can  be  used  ;  this  is  much  less  expensive 
than  the  cyanide  or  alembroth  varieties,  and  is  equally 
useful  for  this  purpose.  A  very  good  fomentation  may 
also  be  made  by  using  ordinary  absorbent  cotton-wool 
instead  of  the  gauze  ;  it  has  the  advantage  of  remaining 
hot  for  a  very  long  time.  Whatever  is  used  for  the 
fomentation  should  be  put  on  as  hot  as  possible,  and 
changed  as  soon  as  it  has  cooled  down  to  the  body 
temperature.  This  will  usually  mean  changing  the 
fomentation  every  fifteen  or  twenty  minutes.  Fomenta- 
tions may  be  made  to  keep  hot  for  longer  than  this  if  they 
are  made  very  thick,  and  a  thick  layer  of  cotton-wool  is 
placed  outside  them. 

A  fomentation  to  be  effective  must  be  hot,  and  must  be 
capable  of  soaking  up  all  the  discharge  from  the  wound. 
This  latter  factor  is  very  important,  as  the  discharge 
from  an  acutely  septic  wound  not  only  swarms  with 
organisms,  but  contains  toxic  material  formed  by  these 
organisms.  This  toxic  material  acts  as  a  poison  to  the 
tissue  cells,  tending  to  paralyze  or  destroy  them,  and  so 
prevent  their  dealing  effectually  with  the  organisms. 

As  soon  as  the  acute  inflammation  in  the  wound  has 
to  some  extent  subsided,  the  fomentations  may  be  left  off 
and  the  wound  dressed  with  damp  gauze — i.e.,  gauze 
with  a  layer  of  oil-silk  or  jaconet  over  it.  Damp  gauze 
has  the  advantage  of  being  more  absorbent  than  dry 
gauze.  The  wound  should  at  first  be  dressed  at  least 
twice  a  day,  and  as  long  as  there  is  any  discharge  the 
wound  ought  to  be  dressed  often  enough  to  insure  its 
being  kept  free  from  the  accumulation  of  pus,  etc.,  in  it. 
At  this  stage  the  edges  of  the  wound  may  with  advantage 
be  drawn  together  with  strapping,  as  already  described. 
When  all  inflammation  has  subsided,  dry  dressings  may 
with  advantage  be  substituted  for  the  damp  ones. 


40     The  After-Treatment  of  Operations 

In  the  case  of  septic  wounds  on  the  extremities,  good 
results  often  follow  the  use  of  the  water-bath  if  the  wound 
is  in  a  suitable  position.  The  water  in  the  bath  should 
be  kept  as  far  as  possible  at  an  even  temperature,  and 
should  be  kept  constantly  flowing  through  so  as  to  keep 
the  water  clean.  Most  limb-baths  are  now  made  with  a 
tap  at  the  bottom  end,  to  which  an  indiarubber  tube  can 
be  attached  passing  to  a  bucket  beneath  the  bed. 
Another  tube  connected  with  a  suitable  receiver  should 
be  arranged  to  allow  water  to  flow  into  the  bath. 

General  Treatment  of  Sepsis. — In  all  cases  where  sepsis 
occurs  in  the  wound  a  free  purge  should  be  administered 
at  the  earliest  opportunity.  Calomel  (5  grains),  followed 
in  four  hours  by  a  dose  of  salts,  is  one  of  the  best  purges 
for  this  purpose,  and  will  do  a  great  deal  to  cut  short 
sepsis  and  bring  down  the  temperature.  A  purge 
administered  immediately  there  is  the  slightest  sign  of 
sepsis  will  occasionally  prevent  the  wound  breaking 
down,  and  when  it  does  not  succeed  in  this,  will  at  any 
rate  do  a  great  deal  to  relieve  the  symptoms.  The  way 
in  which  a  purge  acts  in  diminishing  the  effects  of  sepsis 
in  a  wound  has  not  been  satisfactorily  explained.  That 
it  does  so  cannot  be  doubted.  Purgation  now  takes  the 
place  of  the  blood-letting  which  was  so  popular  in  the 
treatment  of  all  acute  inflammatory  conditions  a  hundred 
years  ago,  and  no  doubt  it  acts  in  much  the  same  way — 
i.e.,  by  depletion.  The  most  probable  explanation  of  the 
value  of  purgation  in  the  treatment  of  sepsis  is  that,  by 
removing  a  large  quantity  of  the  fluid  constituents  of  the 
blood,  it  renders  the  tissues  of  the  body  drier  and  less 
cedematous  ;  obviously  a  wound  which  is  not  sodden  or 
oedematous  will  react  to  sepsis  much  more  favourably 
than  one  that  is. 

With  regard  to  drugs,  no  drugs  except  those  used  as 


Treatment  of  the   Wound  41 

aperients  are  of  much  value.  Quinine  is  supposed  to  be 
efficacious  in  some  cases,  and  especially  in  those  where 
there  are  signs  of  general  septic  infection.  To  be  of 
service  it  should  be  given  in  large  doses,  5  grains  three 
times  a  day. 

5.  Cases  v^^here  Symptoms  of  Septicemia  occur. — 
These  cases  are  now,  fortunately,  rare.  They  still  occur 
occasionally,  however,  and,  when  they  do,  require  prompt 
and  energetic  treatment.  The  chief  points  in  the  treat- 
ment of  these  cases  are  : 

(i)  Disinfection  of  the  wound  as  effectually  as  possible 
and  the  prevention  of  tension  in  it  by  free  drainage. 

(2)  Keeping  up  the  patient's  strength  by  judicious 
feeding.  These  patients  need  to  be  fed  every  two  or 
three  hours. 

(3)  Keeping  the  bowels  acting  freely. 

(4)  Alcohol  in  the  form  of  brandy  or  whisky  should  be 
given  freely — 5  or  8  ounces  daily. 

(5)  The  administration  of  quinine  or  quinine  and  iron 
is  often  useful. 

Serum  and  Vaccine  Treatment  of  Sepsis. 

The  treatment  of  severe  cases  of  sepsis  by  anti- 
streptococcic or  antistaphylococcic  serums,  and  also  the 
more  recent  method  of  using  vaccines  prepared  from  the 
pus  of  the  wound,  while  admirable  in  theory  and  occa- 
sionally successful,  often,  unfortunately,  fail  to  produce 
the  beneficial  results  which  it  is  reasonable  to  expect. 
While  the  success  which  has  attended  these  methods  of 
treatment  does  not  as  yet  justify  us  in  using  them  in 
place  of  the  older  and  well-established  methods,  they 
may  with  advantage  be  used  in  conjunction  with  the 
latter.   Before  usiUj^  any  serum  a  bacteriological  examina- 


42     The  After-Treatment  of  Operations 

tion  of  the  pus  should  be  made,  to  ascertain  what  is  the 
nature  of  the  organism  or  organisms  present,  so  that  a 
suitable  anti-serum  may  be  selected. 

The  injection  of  the  serum,  when  successful,  has  a 
marked  effect  in  reducing  the  temperature,  and,  as  a  rule, 
there  is  a  drop  of  several  degrees  within  a  short  period 
after  the  injection.  It  is  absolutely  necessary  that  the 
serum  should  be  quite  fresh,  and  serum  that  has  been 
prepared  for  more  than  two  weeks  is  useless. 

The  usual  site  for  injection  is  the  loin  or  abdominal 
w^all.  The  serum  should  be  injected  quite  slowly  and 
about  10  c.c.  or  more  used  at  a  time — the  exact  dose 
does  not  seem  to  matter ;  the  injection  should  be  repeated 
every  twenty-four  hours  or  oftener,  if  it  is  doing  good. 
The  serum  should  always  be  obtained  from  some  reliable 
source,  such  as  the  Lister  Institute. 

When  there  is  doubt  as  to  the  exact  nature  of  the 
infection,  a  so-called  polyvalent  serum  may  be  used. 
This  is  prepared  from  several  different  strains  of  strepto- 
cocci, and  consequently  the  chance  of  its  proving  correct 
is  greater.  Very  little  can  be  expected  from  a  single 
injection,  and  if  the  serum  is  to  be  of  any  real  use  it  must 
be  injected  freely  and  repeated. 

In  treating  a  patient  by  vaccines,  his  opsonic  index  is 
first  ascertained,  and  then  a  vaccine  used  which  has  been 
prepared  from  a  pure  culture  of  the  organism  found  in 
the  pus  from  the  wound,  the  object  being  to  raise  the 
patient's  natural  resistance  to  the  infection. 

This  method  of  treatment  is  difficult  and  complicated. 
It  can  only  be  satisfactorily  carried  out  by  a  skilled 
bacteriologist.  It  must  be  confessed  that  this  method  of 
treating  septic  infection  has  been  very  disappointing. 


CHAPTER  III 

THE  TREATMENT  OF  GUNSHOT  WOUNDS 

This  subject  is  such  a  wide  one  that  no  attempt  will  be 
made  to  deal  with  it  m  all  its  aspects,  as  this  would  be 
quite  impossible  in  the  present  volume.  The  following 
remarks  are  the  result  of  experience  gained  by  the  author 
in  attendance  upon  the  wounded  at  King  Edward  VII. 's 
Hospital  for  Officers  and  other  military  hospitals  in  the 
metropolis.  Before  arriving  at  these  hospitals  the 
patients  have  already  been  under  treatment  for  periods 
varying  from  a  few  days  to  a  few  weeks  at  hospitals  in 
France  or  elsewhere.  No  attempt  will  therefore  be  made 
to  describe  here  the  treatment  of  wounds  as  seen  on  the 
field,  or  immediately  after  an  action,  but  only  cases 
as  they  present  themselves  when  they  come  into  the  base 
hospitals  and  into  hospitals  in  England.  By  this  time 
most  of  the  wounds  have  passed  what  we  may  call  the 
first  stage,  and  at  least  a  week  has  usually  elapsed  since 
the  original  injury.  The  methods  of  dealing  with  wounds 
which  are  described  here  are  those  which  the  author  has 
found  most  satisfactory,  and  he  does  not  suggest  that 
they  are  the  only  means  that  can  be  adopted  to  obtain 
good  results ;  but  in  practice  the  results  obtained  by 
these  methods  have  proved  very  satisfactory,  and  he 
hopes  that  they  may  be  found  a  useful  guide  to  those 

43 


44     The  After-Treatment  of  Operations 

surgeons  who  find  themselves  called  upon  to  undertake 
the  care  of  wounded  men,  and  who  have  not  had  much 
previous  experience  of  such  cases. 

Clean  Bullet  Wounds. — These  in  the  present  war 
are  unfortunately  very  few,  but,  nevertheless,  form  a 
certain  proportion  of  the  total.  When  the  bullet  has 
passed  through  soft  parts  without  having  met  with  much 
resistance,  the  entrance  wound  is  quite  small,  and  has 
generally  healed  by  the  time  the  patient  has  reached 
his  destination.  The  exit  wound  is  usually  about  the 
size  of  a  sixpence,  and  is  covered  with  a  dark  brown 
scab.  In  most  instances  the  wounds  have  been  treated 
by  painting  them  with  iodine  and  covering  them  up  with 
aseptic  dressings.  The  best  plan  is  to  continue  this 
treatment,  and  not  to  disturb  the  wounds  in  any  way. 
The  exit  wound  should  be  allowed  to  heal  under  a  scab 
if  it  will  do  so,  and  should  the  scab  separate  an  anti- 
septic dressing  should  be  applied,  or  the  wound  dressed 
with  some  aseptic  ointment,  such  as  one  of  those  men- 
tioned later.  On  no  account  should  any  attempt  he  made  to 
probe  the  wounds,  even  if  they  contain  foreign  bodies. 

The  Removal  of  Bullets  or  Pieces  of  Shell. — -If 
there  is  reason  to  suppose  that  the  bullet  has  lodged,  or  that 
a  piece  of  shell  is  embedded  somewhere  in  the  tissues,  this 
should  not  be  probed  for,  but  at  the  earliest  opportunity 
the  patient  should  be  examined  with  the  X-rays.  If  then 
a  foreign  body  is  found  to  be  present,  the  next  question 
will  be  as  to  whether  it  should  be  removed  or  not.  There 
should  be  no  rule  in  this  matter.  A  foreign  body, 
such  as  a  bullet  or  portion  of  shell,  is  not  necessarily 
harmful  when  retained  in  the  tissues.  Its  removal  is 
only  called  for  if  it  is  causing  symptoms — if,  for  instance, 
it  is  pressing  upon  the  nerves,  interfering  with  the  action 
of  a  muscle  or  joint,  or  if  it  is  causing  pain.     This  does 


The  Treatment  of  Gunshot  Wounds    45 

not,  however,  apply  to  foreign  bodies  within  the  brain, 
which  are  a  different  matter,  and  for  the  treatment  of 
which  the  reader  is  referred  to  other  authorities.  Much 
harm  may  be  done  by  the  removal  of  foreign  bodies 
which  are  not  causing  trouble  or  inconvenience.  The 
patient  may  safely  be  assured  that  no  harm  will  result 
from  the  bullet  being  left  inside  him.  In  the  case  of 
septic  wounds  there  is  more  reason  for  removing  the 
foreign  body,  as  it  often  means  that  the  sinus  will  refuse 
to  close,  although  there  have  been  plenty  of  instances  in 
this  war  where  pieces  of  shell,  etc.,  in  septic  wounds 
have  been  left  and  have  ceased  to  give  any  trouble  at  all. 
It  is  obvious  that  in  many  cases  the  removal  of  pieces  of 
shell  or  bullets  is  quite  impossible  owing  to  their  situa- 
tion. For  instance,  the  writer  saw  one  case  in  which  a 
bullet  had  lodged  in  the  anterior  part  of  the  body  of  the 
fourth  cervical  vertebra,  slightly  injuring  the  posterior 
wall  of  the  pharynx.  It  is  clear  that  the  removal  of 
such  a  foreign  body  would  be  a  most  dangerous  pro-' 
cedure.  No  attempt  was  made  to  remove  it,  and  the 
patient  made  a  perfect  recovery,  and  suffers  no  incon- 
venience from  the  presence  of  the  bullet. 

In  another  case  a  shrapnel  bullet  had  passed  through 
the  sacrum  and  fractured  the  anterior  surface  of  the 
promontory,  where  with  a  finger  in  the  rectum  one  could 
feel  it  bulging  against  the  mucous  membrane  on  the 
posterior  wall  of  the  rectum.  This  foreign  body  was 
also  impossible  of  safe  removal. 

Should  it  be  decided,  owing  to  the  persistence  of  pain 
or  interference  with  a  joint,  that  a  bullet  must  be  re- 
moved, this  should  not  be  attempted  until  the  bullet  has 
been  carefully  localized  by  means  of  Sir  Mackenzie  David- 
son's or  some  other  reliable  X-ray  method.  To  attempt 
to  remove  foreign  bodies  on  the  strength  of  X-ray  photo- 


46     The  After-Treatment  of  Operations 

graphs  without  proper  localization  is  to  ask  for  trouble. 
Such  efforts  will  almost  certainly  result  in  the  patient's 
being  damaged  by  a  large  wound  and  the  foreign  body 
being  left  behind,  owing  to  the  surgeon's  inability'to  find  it. 
With  proper  localization,  and  especially  with  the  aid  of 
Sir  Mackenzie  Davidson's  telephone  probe,  the  surgeon 
should  generally  have  little  difficulty  in  removing  a 
foreign  body  through  a  small  incision.  As  a  rule  no 
attempt  should  be  made  to  remove  pieces  of  bullet,  etc., 
from  the  chest  or  abdominal  cavity. 

Septic  Bullet  Wounds. — The  first  question  that  will 
arise  in  dealing  with  such  wounds  is  whether  the  drainage 
is  adequate  or  not.  If  the  patient's  temperature  is  raised 
at  night,  and  especially  if  in  addition  there  are  local  signs 
of  cellulitis  and  redness  of  the  skin  in  the  neighbourhood 
of  the  wound,  the  drainage  is  almost  certainly  in- 
adequate, and  proper  drainage  must  at  once  be  pro- 
vided. For  this  purpose  it  will  usually  be  necessary  to 
administer  an  anaesthetic  and  to  enlarge  the  wound  or 
wounds,  and  to  pass  the  largest  bore  drainage-tubes  that 
can  be  conveniently  used,  provided  with  plenty  of  side- 
holes  into  every  part  of  the  wound,  being  particularly 
careful  to  see  that  the  most  dependent  part  of  the  wound 
is  properly  drained.  After  this  the  wound  should  be 
irrigated  constantly  with  normal  saline  or  hypertonic 
solutions,  and  should  also  be  fomented  frequently.  For 
this  purpose  the  ordinary  hospital  fomentation  is  quite 
useless.  It  generally  consists  of  two  or  three  layers  of 
boracic  lint,  which  are  usually  cold  before  the  bandages 
have  been  applied.  It  must  always  be  remembered  that 
the  object  of  fomentations  is  not  to  apply  a  warm  dressing, 
but  to  apply  sufficient  heat  to  produce  marked  hypersemia 
of  all  the  tissues  in  the  neighbourhood  of  the  wound, 
and  that  no  fomentation  which  does  not  cause  marked 


The  Treatment  of  Gunshot  Wounds    47 

reddening  of  all  the  tissues  is  of  any  use.  The  best 
fomentation  is  ^  pound  of  cotton-wool  thoroughly  boiled 
in  a  towel  and  then  rung  out  as  dry  as  possible.  This 
fomentation  will  keep  hot  for  at  least  half  an  hour,  and 
should  be  changed  as  often  as  possible,  care  being  taken 
not  to  burn  the  patient,  but  to  go  as  near  it  as  possible. 
Almost  immediate  relief  of  pain  and  considerable  im- 
provement in  the  wound  will  follow  this  treatment.  As 
a  rule,  within  about  forty-eight  hours  the  discharge  will 
have  begun  to  diminish  and  the  temperature  will  have 
come  down.  The  tubes  may  then  be  partially  removed 
or  shortened,  the  patient  being  carefully  watched  to  see 
if  any  rise  in  temperature,  or  increase  in  discharge,  follows 
their  removal.  Irrigation  of  the  wound  should  not  be 
overdone,  The  author  is  of  opinion  that  little  is  to  be 
gained  by  irrigation  of  the  wound  after  the  first  day  or 
so,  unless  it  is  with  the  object  of  washing  out  some 
pocket  in  which  pus  tends  to  accumulate.  The  presence 
of  such  a  pocket,  however,  is  in  itself  evidence  of  inade- 
quate drainage,  and  further  drainage  ought  to  be  provided 
in  order  that  accumulation  of  pus  may  not  occur. 

In  all  these  septic  wounds  the  dressings  should  be 
changed  frequently,  at  least  twice  in  the  twenty-four 
hours,  and  if  possible  oftener,  the  object  being  to  keep 
the  wound  as  free  as  possible  from  pus,  or  contact  with 
pus.  Antiseptics,  especially  strong  ones,  are  of  very 
little  use  at  this  stage,  and  only  tend  to  damage  the 
tissues  and  delay  healing.  Sterilized  water,  or  salt  solu- 
tion, or  very  weak  carbolic,  are  the  best  solutions.  After 
the  wound  has  taken  on  a  healthy  appearance  fomenta- 
tions should  be  stopped,  and  a  wet,  absorbent  dressing 
applied.  By  this  is  meant  a  dressing  which  is  put  on 
wet  and  covered  with  a  large  sheet  of  oil-silk  or  jaconet. 
Wet  dressings  have  the  advantage  of  being  more  absor- 


48     The  After-Treatment  of  Operations 

bent  and  of  not  sticking  to  the  wound.  Consequently 
they  do  not  cause  pain  when  they  are  being  changed,  or 
destroy  the  growing  edge  of  the  wound.  If  the  Avound 
is  dirty,  as  is  usually  the  case,  and  the  surface  of  it  is 
covered  with  sloughs  and  bits  of  dead  tissue,  a  very 
good  dressing  is  peroxide  of  hydrogen,  5  or  10  volumes 
per  cent.  The  best  way  of  applying  this  is  to  soak  small 
pieces  of  gauze  in  the  peroxide  and  pack  these  into  the 
wound  very  lightly.  The  wound  should  not  be  so  packed, 
however,  that  the  packing  projects  above  the  surface  of 
the  skin,  or,  when  the  bandages  are  applied,  there  will  be 
pressure  on  the  wound  which  will  tend  to  cause  pain.  A 
piece  of  gauze  rung  out  of  the  same  peroxide  should  be 
applied  over  the  packing,  and  over  this  a  piece  of  rubber 
sheeting,  in  order  to  keep  it  wet.  This  dressing  should 
also  be  changed  two  or  three  times  a  day.  After  a  few 
days  the  wound  should  take  on  a  healthy  appearance, 
with  bright  red  granulations  covering  all  the  surface. 
When  the  deep  parts  of  the  wound  are  healed,  and  there 
is  left  only  an  area  covered  with  healthy  granulations, 
an  ointment  dressing  may  with  advantage  be  substituted 
for  the  wet  dressing,  and  more  rapid  healing  will  occur. 
It  is  obvious  that  ointment  dressings  must  not  be  applied 
while  there  is  any  discharge  from  deep  sinuses  or  holes. 
The  following  ointment  has  been  found  to  give  excellent 
results  in  wounds  at  this  stage : 

"^  Castor- oil      =  -  .  .  78  per  cent. 

Alcohol          -  .  -  -  10     ,,     ,, 

Scarlet-red    -  -  -  -  4     ,,     ,, 

Amido-azotoluol  -  -  -  8     ,,     ,, 

Sterilized  vaseline,  or  equal  parts  of  castor-oil  and 
sterilized  olive-oil,  may  also  be  used.  The  red  ointment 
should  only  be  applied  in  very  small  quantities,  as  it 
tends  to  spread  and  make  a  mess.     It  has,  however,  the 


The  Treatment  of  Gunshot  Wounds    49 

property  of  healing  up  epithelium  at  an  extraordinary- 
pace.  Another  good  dressing  that  may  be  applied  at  this 
stage,  if  the  wound  is  slow  in  healing,  is  Friar's  Balsam. 

Septic  Bullet  Wounds  involving  Fracture  of  the  Bones. — 
These  are  some  of  the  most  difficult  cases  to  deal  with, 
and  only  a  very  general  outline  of  the  treatment  can  be 
indicated  here.  If  a  compound  fracture  of  one  of  the 
long  bones  has  taken  place,  the  patient  must  be  put  in 
some  splint  which  will  keep  the  limb  in  as  good  a  posi- 
tion as  possible,  and  which  will  allow  of  the  wound 
being  dressed  frequently  and  adequately.  It  is  often  a 
most  difficult  matter  to  arrange  suitable  splints,  more 
particularly  where  large  portions  of  the  bone  are  missing. 
Little  is  to  be  gained  by  removing  broken  fragments 
unless  these  are  obviously  necrosed,  as  they  may  be  of 
use  in  helping  to  fill  up  the  gap  in  the  bone,  many  of 
them  retaining  sufficient  vitality  to  act  as  foci  of  bone- 
formation. 

The  remarks  already  made  on  free  drainage  apply 
with  even  greater  force  to  these  injuries  involving  bone. 
It  is  extraordinary  how  even  the  most  desperate-looking 
injuries,  accompanied  by  sepsis,  will  recover  with  quite 
excellent  results  if  properly  treated,  and  will  leave  good 
and  useful  limbs. 

Secondary  Amputations. — These  should  seldom  be 
called  for,  and  are  always  a  confession  of  failure  on  the 
part  of  the  surgeon.  The  reason  why  a  patient  recovers 
after  the  amputation  of  a  septic  limb  is  that  the  drainage 
of  an  amputation  stump  is  good,  and  that  consequently 
suppuration  of  the  stump  is  not  so  serious  as  that  of  the 
previous  wound  in  the  limb.  In  other  words,  the  surgeon 
amputates  the  limb  because  he  is  unable  otherwise  to 
establish  free  drainage  of  the  wound.  It  is  always  wise 
to  bear  this  in   mind,  and  the  moral  is  that  thorough 

4 


50     The  After-Treatment  of  Operations 

drainage  and  frequent  dressings  should  save  most  limbs. 
The  only  conditions  which  necessitate  amputation  are 
ulceration  of  the  bloodvessels  and  gangrene,  or  a  com- 
pletely disorganized  limb. 

Injuries  of  Joints. — Septic  injuries  of  the  joints  are 
even  more  serious  than  septic  compound  fractures,  by 
which,  however,  they  are  nearly  always  accompanied. 
Experience  has  shown  that  even  in  the  case  of  septic  com- 
pound fractures  associated  with  suppuration  of  a  joint 
excellent  results  can  be  obtained,  and  amputation  is  not 
necessary.  A  more  or  less  stiff  limb  is,  however,  likely 
to  result,  and  this  should  be  borne  in  mind  during  the 
healing  process,  so  that  the  limb,  should  it  become 
fixed,  may  be  in  the  best  position  for  subsequent  utility. 
In  the  case  of  a  badly  septic  joint  accompanied  by  much 
bone  injury,  good  results  may  sometimes  be  obtained  by 
tenotomy  of  the  flexor  muscles,  In  nearly  all  cases  where 
limbs  are  affected  much  may  be  done  by  means  of  mas- 
sage and  exercises,  after  the  wounds  are  healed,  to  obtain 
restoration  of  function.  As  a  rule,  restoration  of  function 
takes  place  much  more  rapidly  in  the  upper  limbs  than 
in  the  lower.  This  is  due  to  the  fact  that  no  weight  has 
to  be  transmitted  in  the  case  of  the  arms. 

Persistent  Sinus. — If  it  is  found  that  there  is  a  sinus 
in  one  of  the  wounds,  which  continues  to  discharge  pus, 
the  inference  is  that  there  is  some  foreign  body  at  the 
bottom  of  it.  This  may  be  a  portion  of  necrosed  bone,  a 
piece  of  clothing  carried  in  on  the  bullet,  a  piece  of  shell, 
etc.  The  author  has  seen  one  case  in  which  a  large  plug 
of  wood  was  driven  into  the  wound.  It  is  obvious  that 
many  of  these  foreign  bodies  will  not  show  in  X-ray 
photographs.  The  proper  treatment  is  to  open  up  the 
sinus,  thoroughly  scrape  it  out,  and  remove  any  foreign 
body  that  is  present.     Healing  will  then  recommence. 


CHAPTER  IV 

HEMORRHAGE  AFTER  OPERATIONS 

The  occurrence  of  haemorrhage  from  the  wound  after  an 
operation  is  one  of  the  most  troublesome  complications 
that  can  arise.  There  are  several  reasons  for  this 
besides  the  mere  fact  of  its  seriousness.  There  is 
nothing  which  is  so  calculated  to  alarm  a  patient,  or  to 
make  him  lose  confidence  in  his  medical  adviser  as 
haemorrhage  from  the  wound,  even  though  it  may  be 
quite  trifling  in  amount.  Blood  seems  to  have  a  par- 
ticularly frightening  effect  upon  most  people,  medical 
men  excepted  ;  and  haemorrhage  after  an  operation, 
coming  on  as  it  usually  does  quite  suddenly  and 
unexpectedly,  often  has  the  effect  of  reducing  the 
patient  to  a  condition  of  panic,  though  the  amount  of 
blood  lost  may  not  be  serious.  It  is  also  a  trying 
complication  to  the  surgeon.  He  has,  as  a  rule,  to  meet 
it  unexpectedly  and  at  a  moment's  notice.  Moreover, 
no  two  cases  are  exactly  alike.  In  some  the  bleeding  is 
easily  stopped,  and  again  in  others  the  greatest  difficulty 
may  be  experienced.  Frequently  the  proper  instruments 
are  not  at  hand  and  reliable  assistance  is  unobtainable. 

In  the  following  description,  haemorrhage  will  be 
divided  into  recurrent  and  secondary.  The  treatment  of 
primary  haemorrhage  does  not  come  within  the  scope  of 
this  work.     By  recurrent  haemorrhage,  or  intermediary 

51 


52     The  After-Treatment  of  Operations 

haemorrhage,  as  it  is  sometimes  called,  is  meant  a  recur- 
rence of  the  primary  bleeding  from  imperfect  arrest.  It 
usually  occurs  within  twenty-four  hours  of  the  operation. 

Recurrent  Haemorrhagre. 

This  may  result  from  various  causes.  The  haemor- 
rhage may  have  been  entirely  stopped  before  sewing  up 
the  wound,  but  owing  to  the  patient's  circulation  being 
feeble  and  the  blood-pressure  low  at  the  end  of  the  opera- 
tion, from  shock  or  some  other  cause,  no  bleeding  takes 
place  from  some  of  the  smaller  vessels  that  have  been 
cut.  When,  however,  the  patient  comes  round  from  the 
anaesthetic,  and  the  shock  has  passed  off,  the  pressure  in 
the  vessels  increases  with  the  improved  circulation,  and 
haemorrhage  occurs.  Again,  some  vessel  or  vessels 
have  become  occluded  by  clot,  and  so  long  as  the  patient 
remains  quiet  this  is  sufficient  to  prevent  bleeding.  On 
coming  round  from  the  anaesthetic,  the  patient  moves 
about,  and  bleeding  results  from  the  displacement  of  the 
clot.  These  are  very  common  events,  and  account  for 
most  of  the  cases  where  haemorrhage  occurs  about  four 
or  five  hours  after  the  operation.  A  less  common  cause, 
but  one  which  may,  nevertheless,  give  rise  to  serious 
trouble,  is  the  partial  division  at  the  operation  of  some 
small  artery.  The  bleeding  may  be  so  trifling  that  it  is 
not  noticed,  or  it  is  thought  that  it  will  stop  when  the 
bandages  are  applied.  When  an  artery,  however  small, 
is  only  partially  divided,  the  contraction  of  the  muscular 
coats  and  sheath  tends  to  keep  the  wound  open,  so  that  a 
vessel  thus  divided  will  go  on  bleeding  almost  indefinitely. 
An  artery  bleeding  into  a  confined  space  acts  like  an 
hydraulic  press,  and  the  pressure  thus  exerted  upon  the 
interior  of  the  wound  may  be  very  considerable.  When 
bleeding  is  taking  place  in  this  way  into  a  wound,  a  very 
large  haematoma   may  form,  and  the   skin   round  the 


Hemorrhage  after  Operations         53 

wound  be  stripped  up  for  a  considerable  distance.  Also, 
owing  to  the  small  size  of  the  vessel  which  is  bleeding, 
the  haemorrhage  takes  place  slowly,  and  often  does  not 
give  any  external  evidence  of  its  presence  for  some  hours 
after  the  operation. 

The  following  case  illustrates  this  form  of  recurrent 
haemorrhage : 

A  man  of  about  forty-five  years  of  age  had  his  right  testicle 
removed  for  tubercular  disease.  All  bleeding  was  stopped  at  the 
operation,  and  the  wound  was  sewn  up.  At  12.30  p.m.,  and 
about  eight  hours  after  the  operation,  the  patient  noticed  that  the 
dressings  were  wet,  and  on  examination  the  nurse  discovered  that 
there  was  a  quantity  of  blood  on  them  and  in  the  bed.  The  house- 
surgeon  was  sent  for,  and  on  his  removing  the  dressings  it  was 
found  that  an  enormous  haematoma  had  formed  under  the  wound 
and  had  stripped  up  the  skin  over  the  abdominal  wall  half-way 
to  the  umbilicus.  It  was  at  first  thought  that  the  ligature  on  the 
cord  had  given  way.  An  anassthetic  was  administered  and  the 
wound  opened  up  ;  it  was  then  found  that  the  bleeding  was  taking 
place  from  a  small  subcutaneous  artery  not  much  larger  than  a  pin 
in  diameter.  The  vessel  was  partially  divided,  and  had  no  doubt 
been  wounded  by  the  needle  in  sewing  up  the  wound.  The  vessel 
was  clipped  and  ligatured,  and  the  wound  sewn  up  again  after 
clearing  out  the  clot.  In  this  case,  in  spite  of  the  slowness  with 
which  the  bleeding  must  have  taken  place,  and  the  comparatively 
small  amount  of  blood  lost,  the  patient  was  suffering  from  very 
pronounced  symptoms  of  collapse. 

Other  causes  of  recurrent  haemorrhage  are  softening  or 
slipping  of  a  Ugature,  and  failure  to  secure  the  distal  end 
of  a  divided  artery  ;  in  the  latter  case,  bleeding  will  take 
place  as  soon  as  the  collateral  circulation  is  established. 

Treatment  of  Recurrent  Hcsmorrhage. — The  best  treat- 
ment, when  it  can  be  carried  out,  is  to  at  once  reopen  the 
wound  and,  ligature  or  secure  the  bleeding  vessel.  In 
some  cases  pressure  alone  may  prove  sufficient,  but,  as 
already  pointed  out,  this  cannot  be  relied  upon. 


54     The  After-Treatment  of  Operations 

An  anaesthetic  should,  as  a  rule,  be  administered,  as  it 
is  next  to  impossible  to  make  certain  how  much  may 
have  to  be  done  before  the  bleeding  is  stopped  ;  also,  the 
various  steps  of  opening  the  wound  and  securing  the 
vessel  that  is  bleeding  can  then  be  carried  out  with  much 
greater  deliberation,  and  there  will,  in  consequence,  be 
less  danger  of  the  wound  becoming  infected. 

If  the  haemorrhage  is  found  to  have  stopped  by  the 
time  the  surgeon  reaches  the  patient,  or  if  it  should  stop 
after  the  administration  of  the  anaesthetic,  the  wound 
should  nevertheless  be  opened  if  the  previous  bleeding 
has  been  at  all  severe,  as  it  will  probably  recur  again, 
and  the  risk  of  this  is  greater  than  that  of  opening  the 
wound.  Moreover,  the  presence  in  the  wound  of  a  large 
mass  of  blood-clot  will  very  materially  delay  healing,  and 
is  much  better  removed. 

In  cases  where  the  bleeding  is  venous  instead  of 
arterial,  pressure  should  be  carefully  applied  over  the 
bleeding  point,  and  the  limb  or  part  well  raised  on 
pillows,  etc.  Care  should  be  taken  to  see  that  there  are 
no  bandages  or  straps  of  splints,  etc.,  constricting  the 
parts  above  the  wound,  as  this  is  the  commonest  cause 
of  such  venous  bleeding,  all  that  is  required  in  many 
cases  being  the  removal  of  the  constricting  bands  and 
the  elevation  of  the  part. 

Recurrent  Hsemorrhag"e  from  the  Wound  as  the 
Result  of  Some  Constitutional  Condition  of 
the  Patient. 

The  treatment  of  recurrent  haemorrhage  by  opening 
the  wound  and  securing  the  bleeding  vessel  previously 
mentioned,  though  the  best  procedure  in  most  cases,  is 
not  always  applicable.     There  are  some  cases  where  a 


Hsimorrhage  after  Operations         55 

general  oozing  of  blood  occurs  from  the  wound.  This 
oozing  may  continue  uninterruptedly,  or  it  may  stop,  and 
after  an  interval  of  hours  or  days  start  afresh.  The 
bleeding  is  usually  not  copious,  but  the  quantity  lost  is 
often  considerable,  and  the  patient  soon  gets  into  a  most 
dangerous  condition. 

In  some  cases  of  this  nature  the  bleeding  does  not 
come  on  for  some  days  after  the  operation.  The  cause 
is  probably  always  constitutional,  and  is  due  to  some 
blood  change  which  interferes  with  the  proper  clotting  of 
the  blood.  What  the  exact  nature  of  these  blood  changes 
is  has  not  yet  been  determined.  One  of  the  best  explana- 
tions seems  to  be  that  it  is  due  to  an  absence  or  deficiency 
of  the  calcium  salts.  The  constitutional  conditions 
in  which  this  type  of  haemorrhage  is  most  commonly 
met  with  are  haemophilia,  jaundice,  and  leucocythemia. 
There  are,  however,  cases  which  do  not  apparently  come 
under  the  head  of  any  of  these  three  diseases,  in  which 
bleeding  of  this  nature  occurs,  and  it  seems  probable  that 
there  are  other  conditions,  as  yet  unrecognised,  in  which 
similar  blood  changes  take  place. 

The  best  way  of  treating  these  cases  is  by  the  adminis- 
tration of  calcium  lactate  in  large  doses.  This  drug 
is  of  most  value  in  preventing  haemorrhage,  but  unfortu- 
nately it  is  only  seldom  that  we  are  able  to  foresee  such 
haemorrhage. 

If  calcium  chloride  is  administered  in  large  doses  as 
soon  as  the  haemorrhage  occurs,  it  is  usually  effectual  in 
stopping  the  bleeding  in  a  short  time,  though,  since  it 
acts  by  correcting  a  constitutional  deficiency  of  the  blood, 
it  cannot  be  expected  to  act  rapidly. 

It  should  be  given  in  doses  of  from  13  to  20  grains  or 
more  three  times  a  day  either  by  the  mouth  or  rectum. 

The  administration  of  very  large  doses  of  this  dru^- 


56     The  After-Treatment  of  Operations 

would  appear  on  theoretical  grounds  to  be  dangerous, 
though  the  author  knows  of  no  cases  where  it  has  proved 
so.  Large  doses  administered  to  animals  cause  intra- 
vascular clotting,  and  one  would  expect  to  find  thrombosis 
as  a  possible  consequence  of  the  too  free  administration 
of  the  drug. 

The  local  application  of  adrenalin  is  also  sometimes 
effectual  in  these  cases. 

Jaundice. — When  patients  are  suffering  from  jaundice 
at  the  time  of  the  operation,  as  is  often  the  case  in  opera- 
tions for  occlusion  of  the  common  bile-duct,  they  are  very 
liable  to  bleed  in  this  way.  The  bleeding  takes  place 
from  all  parts  of  the  wound  and  even  from  the  stitch- 
holes.  Pressure  alone  is  seldom  of  much  use  in  stopping 
the  haemorrhage.  Styptics  may  be  tried,  preferably  supra- 
renal extract  or  Ruspini's  styptic.  These  styptics  are 
best  applied  by  soaking  narrow  pieces  of  lint  in  them, 
and  then  packing  the  lint  into  the  wound  and  applying 
pressure  over  it.  Mr.  Mayo-Robson  has  drawn  atten- 
tion to  the  value  of  calcium  chloride  in  large  doses  in 
the  treatment  of  these  cases  ;  he  advises  the  drug  to 
be  given  by  the  rectum  in  60-grain  doses  three  times  a 
day,  until  all  signs  of  oozing  from  the  wound  have 
ceased. 

HEMOPHILIA. — These  are  most  serious  cases^  and  often, 
in  spite  of  all  treatment,  result  fatally.  Ruspini's  styptic  or 
suprarenal  extract  should  be  applied  locally  and  be  aided 
by  pressure.  These  drugs  can  be  given  internally  at  the 
same  time.  Ruspini's  styptic  can  be  given  in  doses  of 
ID  minims  hourly  in  about  i  ounce  of  water. 

Calcium  lactate  in  10  to  20  grain  doses,  given  internally> 
is  also  sometimes  efficacious ;  it  should  be  given  as  soon 
as  possible  after  a  diagnosis  of  haemophilia  has  been 
made,  and  repeated,  as  it  takes  some  time  to  act. 


Hasmorrhage  after  Operations         ^y 

Weil  has  recently  stated  that  fresh  human  or  animal 
serum,  when  added  in  a  dose  of  3  drops  to  3  c.c.  of  the 
blood  of  a  hgemophilic  subject,  will  favour  coagulation  to 
a  marked  degree  in  the  inherited  form,  and  absolutely  in 
the  accidental  form  of  the  disease.  In  the  adult,  from 
10  to  20  c.c.  of  fresh  serum  is  sufficient  for  a  venous,  and 
from  20  to  30  c.c.  for  a  subcutaneous,  injection.  In 
children  half  these  doses  should  be  used.  The  best 
serum  next  to  that  of  man  is  that  of  the  horse  or  rabbit. 
If  these  are  unobtainable,  Weil  advises  using  anti- 
diphtheritic  serum,  which  is  readily  obtainable. 

Direct  transfusion  of  blood  from  a  healthy  person  has 
been  used  successfully  in  cases  of  haemophilia.  This  re- 
quires the  performance  of  a  temporary  arterial  anasto- 
mosis between  the  bloodvessels  of  the  patient  and  the 
person  who  is  willing  to  give  the  blood.  This  is  a  delicate 
operation  requiring  considerable  care.  There  is  no  serious 
risk  to  the  donor  of  the  blood,  but  a  certain  amount  of 
temporary  weakness  necessarily  results.  The  amount  of 
blood  transfused  should  be  about  2  pints. 

Leucocythemia. — This  is  another  disease  in  which 
bleeding  of  this  nature  often  occurs.  The  treatment  is 
the  same  as  in  the  previous  instances. 

Secondary  Haemorrhag'e. 

By  this  term  is  usually  meant  haemorrhage  starting  at 
any  time  from  one  day  to  three  weeks  after  the  operation. 
The  cause  is  either  failure  in  the  healing  of  one  of  the 
vessels  in  the  wound  or  ulceration  into  a  bloodvessel ;  it 
usually  results  from  septic  arteritis,  and  consequently  does 
not  occur  in  aseptic  wounds.  Another  factor  of  importance 
is  disease  of  the  arterial  wall ;  thus  extensive  atheroma  of 
the  arterial  walls  may  be  the  cause  of  secondary  haemor- 
rhage in  the  aged.     The  treatment  is  the  same  as  in  the 


58     The  After-Treatment  of  Operations 

case  of  recurrent  hemorrhage  ;  that  is  to  say,  opening 
up  the  wound  and  securing  the  artery,  except  that  it  is 
even  more  important  to  do  this  immediately  any  signs  of 
bleeding  show  themselves.  The  bleeding  is  usually 
slight  at  first,  but  later  may  be  furious,  and  it  is  therefore 
particularly  important  to  deal  with  it  in  the  early  stage 
before  this  has  occurred.  Pressure  should  be  applied 
over  the  main  vessel  on  the  proximal  side  of  the  bleeding 
point  if  this  is  possible,  and  then  an  attempt  made  to 
secure  the  bleeding  vessel.  In  cases  where  the  wound 
is  in  a  sloughy  condition  this  is  often  a  very  difficult 
matter,  and  the  vessel  cannot  be  secured  by  a  ligature. 
Under  these  circumstances  a  good  plan  is  to  underpin  it 
(acupressure).  This  may  be  done  by  passing  a  stitch 
deeply  through  the  tissues  so  as  to  include  the  vessel, 
and  then  tying  the  stitch  ;  or  another  way  is  to  pass  a 
hare-lip  pin  beneath  the  vessel,  and  compress  the  artery 
by  figure-of-eight  turns  made  with  silk  round  the  ends  of 
the  pin  and  over  the  artery,  or  a  clip  can  be  put  on  to  the 
bleeding  point  and  left  in  situ.  These  methods  failing, 
recourse  may  be  had  to  the  actual  cautery.  One  of  the 
great  objections  to  the  latter  is  the  liability  to  fresh 
haemorrhage  when  the  sloughs  separate. 

Secondary  Hemorrhage  from  Bullet  or  Shell 
.Wounds. — Secondary  haemorrhage  in  wounds  produced  by 
shell  or  bullets  is  often  a  most  serious  accident,  and  may 
call  for  the  very  greatest  skill  and  promptitude  in  order  to 
save  the  patient's  life.  Much  will  depend  upon  the  nature 
of  the  wound,  and  no  definite  rules  can  be  laid  down  for  the 
treatment  of  such  cases,  as  the  conditions  cannot  always 
be  foreseen,  and  very  often  the  surgeon  will  have  to 
depend  upon  his  own  ingenuity  and  resource  in  order  to 
stop  the  bleeding.  Some  of  the  worst  cases  are  those  in 
which   there  is  a  septic  wound  in  the  neighbourhood  of 


Hsmorrhage  after  Operatioils         59 

one  of  the  main  arterial  trunks.  All  patients  with  such 
wounds  should  be  kept  very  quiet  until  healing  has 
reached  a  stage  at  which  secondary  haemorrhage  is  no 
longer  to  be  feared.  Unfortunately,  secondary  haemor- 
rhage will  sometimes  occur  no  matter  how  carefully  the 
patient  is  treated.  The  bleeding  generally  occurs  at  any 
time  from  a  week  onwards,  and  is  due  to  some  ulcer 
eating  its  way  through  the  coats  of  the  artery.  Usually 
the  haemorrhage  begins  slowly  by  a  slight  leak,  and  this 
is  the  stage  at  which  the  surgeon  should,  if  possible, 
interfere.  Presently,  as  the  hole  in  the  vessel  enlarges, 
the  bleeding  will  become  furious.  The  proper  treatment 
is  immediately  to  give  the  patient  a  hypodermic  of 
morphia  and  to  administer  an  anaesthetic.  If  the  bleeding 
vessel  can  easily  be  reached  through  the  wound,  the 
surgeon  should  expose  it  and  ligature  the  main  vessel 
above  and  below  the  bleeding-point.  Before  attempting 
this,  however,  the  main  vessel  on  the  central  side  should, 
if  possible,  be  controlled  by  an  assistant,  in  order  to  save 
any  furious  bleeding  during  the  operation.  It  will  often 
happen  that  it  is  not  possible  or  advisable  to  reach  the 
vessel  through  the  wound,  in  which  case  the  main  artery 
as  near  as  possible  above  the  wound  must  be  cut  down 
upon  and  ligatured.  When  the  vessel  concerned  is  the 
femoral  artery  or  vein,  or  the  axillary  artery  in  the  arm, 
there  will  be  considerable  danger  of  subsequent  gangrene 
of  the  limb,  more  particularly  in  the  case  of  the  femoral 
artery,  In  order  to  prevent  this,  so  far  as  is  possible,  the 
limb  should  be  kept  warm  and  should  be  elevated.  In 
the  case  of  the  leg  a  very  good  plan  is  to  nurse  the 
patient  lying  on  his  face,  so  as  to  take  the  pressure  off  the 
vessels  at  the  back  of  the  thigh  through  which  the 
collateral  circulation  will,  in  the  main,  have  to  be  estab- 
lished.    If  signs   of    gangrene  occur,  amputation  offers 


6o     The  After-Treatment  of  Operations 

the  only  means  of  saving  the  patient's  life.  In  some 
cases  ligature  of  the  vessel  will  not  be  possible,  especially 
where  the  wound  is  somewhere  in  the  trunk.  Firm 
plugging  must  then  be  resorted  to,  together  with  measures 
to  keep  down  the  patient's  blood-pressure.  The  following 
cases  which  occurred  recently  will  illustrate  the  difficulties 
that  may  be  experienced. 

1.  An  officer  who  had  been  wounded  at  the  Battle  of 
the  Marne  was  brought  back  to  one  of  the  hospitals  in 
London  with  a  bullet  wound  of  the  left  loin.  The 
bullet  had  smashed  the  wing  of  the  ilium  and  penetrated^ 
together  with  fragments  of  the  bone,  behind  the  peri- 
toneum through  the  lumbar  muscles  to  the  opposite  side 
of  the  spine.  The  fragment  had  been  driven  forwards, 
and  had  opened  the  sigmoid  flexure.  The  patient  had  a 
f cecal  fistula  through  a  compound  septic  fracture  of  the 
ilium,  and,  soon  after  his  admission,  leakage  of  arterial 
blood  through  the  wound.  The  bleeding  appeared  to  be 
coming  from  one  of  the  lumbar  arteries.  In  order  to 
deal  with  this  condition  the  patient  was  put  under  an 
anaesthetic,  and  the  abdomen  opened  on  the  left  side. 
The  hole  in  the  sigmoid  was  found,  excised,  and  sewn  up. 
The  posterior  wound  was  then  investigated  and  plugged 
as  far  back  as  the  spine  in  order  to  control  the  haemor- 
rhage, which  had  become  severe.  Two  days  later  a 
tremendous  haemorrhage  occurred  suddenly  in  spite  of 
the  plugging,  and  very  nearly  proved  fatal.  Fortunately, 
it  was  again  controlled  by  plugging,  and  the  patient  made 
a  good  recovery. 

2.  An  officer  was  wounded  at  Ypres  by  a  bullet  which 
entered  through  the  left  cheek,  passed  behind  the  last 
molar  tooth  in  the  upper  jaw,  and  through  the  centre  of 
the  soft  palate,  and  emerged  through  the  right  tonsil  in 
the  line  of  the  carotid  vessels  on  the  right   side  of  the 


Haemorrhage  after  Operations         6i 

neck.  He  was  admitted  to  the  hospital  in  London  eight 
days  after  injury.  Both  wounds  were  almost  healed, 
and  his  only  complaint  was  of  a  sore  throat,  There  was 
a  septic-looking  wound  in  the  soft  palate  and  a  haematoma 
on  the  right  side  of  the  neck,  but  no  pulsation.  He  had 
a  good  pulse  in  the  right  temporal  artery.  He  appeared 
to  have  quite  recovered  from  the  wound.  While  he  was 
asleep,  however,  on  the  twelfth  day  a  large  vessel,  prob- 
ably the  internal  carotid  artery,  gave  way  into  the 
mouth  behind  the  soft  palate.  He  woke  up  with  tre- 
mendous haemorrhage,  which  continued  until  he  fainted, 
when  it  fortunately  stopped.  The  author,  under  whose 
care  he  was,  was  immediately  sent  for.  He  found  the 
patient  almost  dead,  but  the  haemorrhage  had  stopped. 
It  was  decided  that  it  was  not  wise  to  risk  a  recurrence 
of  the  haemorrhage  when  the  pulse  began  to  recover. 
Accordingly,  in  spite  of  the  danger  of  shock,  the  patient 
was  put  under  an  anaesthetic  at  two  o'clock  in  the 
morning,  and  the  common  carotid  was  tied  just  below  the 
bifurcation.  The  patient  was  then  kept  lightly  under 
morphia  for  the  next  forty-eight  hours.  He  made  a 
perfect  recovery. 


Internal  Hsemorphag'e. 

The  evidence  of  this  will  usually  be  the  onset  of 
symptoms  of  syncope  and  collapse,  which  are  otherwise 
difficult  to  account  for,  accompanied  by  signs  indicating 
the  presence  of  free  fluid  in  the  abdomen  or  chest.  It  is 
of  interest  to  notice  that  a  high  temperature  may  accom- 
pany internal  hagmorrhage.  This  temperature  is  probably 
due  to  the  absorption  of  some  of  the  constituents  of  the 
blood.     It  is  advisable  to  bear  this  in  mind-  -as  otherwise 


62     The  After-Treatment  of  Operations 

the  symptoms  may  be  ascribed  to  sepsis,  and  the  true 
nature  of  the  case  not  detected  till  too  late. 

The  proper  treatment  is  to  at  once  open  up  the  wound, 
expose  the  bleeding  point,  and  secure  it.  This  in  the 
case  of  haemorrhage  into  the  abdominal  cavity  often 
means  an  operation  of  equal  or  even  greater  gravity  than 
the  original  one.  The  proper  treatment  of  internal 
haemorrhage  under  such  circumstances,  therefore,  may 
be  a  matter  of  the  greatest  difficulty,  or  even  impossible. 
The  facilities  for  operating  may  not  be  at  hand,  or  the 
condition  of  the  patient  may  be  such  that  reopening  ths 
abdomen  is  out  of  the  question.  When  the  source  of  the 
haemorrhage  cannot  be  dealt  with  directly,  the  patient 
should  be  kept  as  quiet  as  possible,  ice  should  be  applied 
over  the  probable  source  of  bleeding,  and  morphia  should 
be  administered  subcutaneously  to  reduce  the  blood- 
pressure  and  to  keep  the  patient  quiet.  Stimulants  are 
best  avoided,  as,  by  raising  the  blood-pressure,  they  tend 
to  increase  the  haemorrhage. 


The  Treatment  of  Hsemorrhagre  after  Special 
Operations. 

HEMORRHAGE    AFTER     THE    REMOVAL    OF     ToNSILS     OR 

Adenoids. — The  following  causes  of  severe  haemorrhage 
after  the  removal  of  tonsils  or  adenoids  are  given  by 
Cordes  :* 

1.  Haemophilia. 

2.  Cardiac  disease  or  arterio -sclerosis  (in  adults). 

3.  Anomalies  in  the  course  of  the  internal  carotid. 

4.  A  preparatory  application  of  cocaine. 

5.  Small    shreds   of  vegetations  remaining  partly  at- 

•  W.  Milligan,  Med,  Ami.,  1901. 


Hasmorrhage  after  Operations         63 

tached  to  the  pharynx ;  the  haemorrhage  ceases  when  they 
are  removed. 

6.  Occasionally  severe  haemorrhage  results  in  females 
if  the  operation  be  performed  at  the  time  of  the  menstrual 
period. 

Hemorrhage  after  Removal  of  Tonsils. — The  patient 
should  be  made  to  sit  up  and  breathe  with  the  mouth 
well  open,  preferably  in  a  draught  of  cold  air,  as,  for 
instance,  in  front  of  an  open  window.  The  upright 
position  tends  to  empty  the  vessels  and  the  cold  to  make 
them  contract.  Ice  or  iced  water  may  be  given  to  drink, 
or  iced  water  applied  to  the  side  of  the  face.  This  is  all 
that  is  necessary  in  slight  cases  of  haemorrhage,  and 
serious  haemorrhage  is  very  uncojnnion. 

If,  however,  the  bleeding  is  severe,  and  will  not  yield 
to  such  simple  measures,  the  following  may  be  tried  : 
When  the  bleeding  is  from  the  tonsil,  a  piece  of  lint  or  a 
small  Turkey  sponge  previously  soaked  in  turpentine  oi 
some  other  styptic  (perchloride  of  iron  should  not  be 
used)  is  twisted  round  the  end  of  a  clip  or  pair  of  tongue 
forceps  and  pressed  against  the  bleeding  surface,  counter 
pressure  being  at  the  same  time  made  over  the  position 
of  the  tonsil  outside.  Pressure  should  be  maintained  for 
some  minutes  until  all  bleeding  has  ceased.  If  no  styptic 
is  available,  the  lint  or  sponge  must  be  wrung  out  of  hot 
water  (any  heat  under  a  temperature  of  100°  F.  will  tend 
to  increase  the  bleeding  rather  than  to  stop  it). 

If  an  artery  is  spurting,  or  the  bleeding  refuses  to 
stop  with  the  above  measures,  a  gag  should  be  placed  in 
the  mouth,  and  an  attempt  made  in  a  good  light  to  clip 
the  bleeding  point.  If  this  is  successful,  the  clip  may  be 
left  on  for  a  few  minutes  or  the  vessel  twisted. 

Hemorrhage  from  the  Naso -pharynx  after  the  Removal  of 
Adenoids. — The  bleeding,  though   often   severe   at   first, 


64      The  After-Treatment  of  Operations 

stops,  as  a  rule,  after  a  minute  or  so.  If  it  should  not 
stop,  pressure  should  be  applied  to  the  bleeding  surface 
by  passing  a  small  Turkey  sponge  up  behind  the  soft 
palate  and  pressing  it  against  the  posterior  pharyngeal 
wall  with  the  finger ;  or  the  sponge  can  be  wrung  out  of 
spirits  of  turpentine,  or  any  other  suitable  styptic,  and 
applied  in  the  same  manner.  The  sponge  can  be  held 
in  place  either  by  the  finger  or  a  clip.  Another  plan  is 
to  wrap  a  strip  of  lint  round  the  end  of  a  Gottstein's  ring- 
knife  (which  will  be  at  hand),  and  press  on  the  bleeding 
point  with  it.  When  it  is  not  possible  to  control  the 
bleeding  by  any  of  the  above  measures,  and  it  seems 
probable  that  the  bleeding  is  due  to  the  accidental 
wounding  of  an  abnormally-situated  internal  carotid  or 
other  vessel,  it  may  sometimes  be  necessary  to  ligature 
the  common  carotid  artery.  This  is,  however,  a  very 
doubtful  expedient,  as,  if  the  blood  is  coming  from  the 
internal  carotid,  it  is  unlikely  that  the  haemorrhage  will 
cease  even  after  ligature  of  that  vessel,  owing  to  the 
free  communication  from  the  opposite  side.  It  should 
certainly  not  be  ligatured  unless  it  is  found  that  compress- 
ing the  vessel  in  the  neck  controls  the  bleeding. 

Bleeding  from  the  Nose  after  Operations  for  the 
Removal  of  Polypi  or  one  of  the  Turbinate  Bones. 
— Syringing  the  nose  out  with  iced  or  hot  water  will 
usually  suffice,  or  a  strip  of  lint  soaked  in  adrenalin  or 
some  other  styptic  may  be  placed  in  the  nose  for  a  few 
minutes.  In  cases  of  severe  haemorrhage,  the  following 
plan,  which  is  advised  by  Mr.  Shield,*  may  be  tried :  A 
small,  soft  Turkey  sponge  of  suitable  size  is  wrung  out 
of  spirits  of  turpentine,  and  passed  up  behind  the  soft 
palate ;  it  is  then  seized  by  forceps  passed  through  the 
nose  from  in  front,  and  the  latter  are  pulled  upon  so  as 
*  '  Lectures  on  Nasal  Obstruction,' 


Hasmorrhage  after  Operations  65 


to  draw  the  sponge  against  the  posterior  nares. 
will  stop  any  bleeding  from  the  back  of  the 
nares,  and  in  the  case  of  bleeding  further 
forward,  strips  of  lint  can  be  pushed  into 
the  nostril  from  which  the  blood  is  coming 
while  the  sponge  is  in  position,  the  sponge 
preventing  the  lint  from  going  into  the 
naso- pharynx.  When  the  haemorrhage 
has  in  this  way  been  controlled,  the  forceps 
and  sponge  can  be  cautiously  removed, 
leaving  the  plug  in  place.  Other  methods 
are  to  plug  the  nose  in  the  ordinary  way 
for  epistaxis,  or  to  insert  an  inflatable  india- 
rubber  tampon  (Fig.  14).  If  a  plug  is 
inserted,  it  should  be  removed  in  twenty- 
four  hours. 

HEMORRHAGE       AFTER        ToOTH-EXTRAC- 

TiON. — This  is  seldom  of  any  consequence, 
and  when  it  is,  usually  results  from  haemo- 
philia, or  some  other  constitutional  con- 
dition in  the  patient.  The  tooth-socket 
should  be  plugged  with  cotton-wool  from 
the  bottom,  the  wool  having  been  first 
soaked  in  some  suitable  styptic  ;  then  a 
pad  of  folded  lint  should  be  placed  on  the 
top  of  the  plug.  This  pad  should  be  of 
sufificient  thickness  to  prevent  the  teeth 
meeting,  so  that  when  the  jaw  is  closed 
and  tied  up  tight  with  a  jaw-bandage,  pj^ 
pressure  is  maintained  upon  the  plug. 

A  good  plan  in  some  cases  is  to  put  a  stitch  th 


This 


*  The  tampon  is  smeared  with  vaseline,  passed  into  the  nose, 
and  inflated,  - 


66     The  After-Treatment  of  Operations 

the  gum  on  each  side  of  the  socket  and  tie  it  tightly,  so 
as  to  close  the  cavity.  This  plan  is  a  very  useful  one, 
especially  when  there  is  not  a  tooth  on  each  side  of  the 
empty  socket.  The  most  troublesome  cases  of  haemor- 
rhage after  dental  operations  are  those  resulting  from  a 
wound  of  the  posterior  palatine  artery.  This  accident 
may  happen  from  the  forceps  slipping,  or  from  the 
improper  use  of  an  elevator  on  an  upper  molar.  Pressure 
may  be  tried,  or  an  attempt  made  to  clip  the  vessel. 
This  is,  however,  seldom  successful,  as  the  vessel  usually 
lies  in  a  groove  in  the  hard  palate.  The  bleeding  can 
be  stopped  by  pushing  a  small  wooden  plug  up  the 
posterior  palatine  canal  The  position  of  the  posterior 
palatine  canal  is  about  a  quarter  of  an  inch  to  the  inner 
side  of  the  last  molar  tooth.  An  incision  must  be  made 
in  this  situation  through  the  mucous  membrane  and  the 
plug  inserted.  It  should  be  removed  at  the  end  of 
twenty-four  hours. 

HEMORRHAGE  AFTER  REMOVAL  OF  THE  ToNGUE. If  the 

wound  has  been  kept  aseptic  after  the  operation,  this  but 
rarely  occurs.  When  haemorrhage  does  occur,  however, 
it  is  usually  very  dangerous.  If  the  whole  tongue  has 
been  removed,  it  is  best  to  leave  a  silk  thread  through  the 
stump,  and  to  secure  this  outside  the  mouth  with  a  piece 
of  strapping.  In  case  of  bleeding  taking  place,  the  stump 
can  then  be  easily  pulled  forward  and  the  bleeding  point 
clipped.  If  no  such  thread  has  been  placed  through  the 
stump,  the  latter  must  be  caught  hold  of  with  a  clip  or 
vulsellum  forceps  and  pulled  well  forwards,  so  as  to 
expose  the  bleeding  point.  Two  or  three  clips  should  be 
kept  handy  in  cases  where  there  is  any  possibility  of 
haemorrhage.  If  secondary  haemorrhage  does  occur,  it 
will  probably  take  place  from  a  week  to  ten  days  after 
the  operation. 


Hasmorrhage  after  Operations         6y 

Bleeding  from  the  Intercostal  Artery  after 
Operation  for  Empyema,  etc. — The  bleeding  point 
should  be  picked  up,  if  possible,  with  a  clip,  and 
ligatured,  the  wound,  if  necessary,  being  enlarged  to 
expose  the  vessel.  Or  the  centre  of  a  square  piece  of 
lint  may  be  pushed  into  the  wound,  and  the  cavity  so 
formed  packed  with  cotton-wool ;  then,  by  pulling  on  the 
lint,  the  bleeding  can  be  controlled. 

Bleeding  from  the  Fr^nal  Artery  after  Cir- 
cumcision, ETC. — The  artery  should  be  picked  up  with 
a  clip,  if  possible,  and  ligatured.  If  this  is  difficult, 
a  stitch  may  be  inserted  beneath  the  vessel  and  tied 
over  it.  Or  a  pin  can  be  passed  through  beneath  the 
vessel  and  a  figure  of  eight  made  over  it  with  silk.  A 
strip  of  lint  soaked  in  lotio  plumbi  will  often  stop  the 
slight  haemorrhage  that  is  sometimes  seen  after  circum- 
cision, and  makes  an  excellent  dressing. 

Bleeding  from  the  Perineum  after  Lithotomy, 
ETC — Any  bleeding  points  that  can  be  seen  must  be 
picked  up  and  ligatured,  or  the  clip  left  on.  This  failing, 
a  tube  with  a  petticoat  tied  round  it  should  be  inserted 
into  the  wound,  and  gauze  or  wool  packed  round  the 
tube.  Two  strings  are  then  attached  to  the  end  of  the 
tube,  and  fastened  to  a  band  round  the  patient's  waist. 
If  there  is  no  necessity  for  draining  the  bladder  through 
the  wound,  the  latter  may  be  simply  plugged  in  the 
ordinary  way,  and  pressure  made  on  the  perineum  by  a 
perineal  bandage.  This  bandage  is  an  excellent  method 
of  applying  pressure  to  the  perineum.  It  is  put  on  as 
follows  :  A  piece  of  4-inch  bandage  is  tied  round  the 
waist,  and  the  ends  cut  off.  The  roll  of  bandage  is  then 
passed  under  this  behind,  and  carried  forwards  across 
the  perineum,  beneath  the  waist-bandage  in  front,  and 
back  again.  The  two  free  ends  of  the  bandage  are  then 
pulled  upon,   and   tied    together    in    the    centre    of   the 


68      The  After-Treatment  of  Operations 

perineum.  In  this  way  considerable  pressure  can  be 
exerted  on  any  desired  point. 

HEMORRHAGE  AFTER  OPERATIONS  ON   THE  BlADDER. 

This  is  very  seldom  met  with,  but  may  occur  after  opera- 
tions for  the  relief  of  enlarged  prostate  or  for  the  removal 
of  growths,  especially  papillomata  (villous  tumour).  It 
may  also  follow  lithotrity,  but  should  not  do  so  if  the 
operation  has  been  properly  performed.  Again,  it  may 
result  from  the  too  rapid  evacuation  of  an  overdistended 
bladder,  especially  in  old  men.  The  great  difficulty  in 
dealing  with  the  bleeding  in  these  cases  depends  upon 
the  fact  that  the  bladder  is  usually  filled  with  blood-clot, 
and  nothing  can  be  done  until  this  has  all  been  removed. 
As  large  a  catheter  as  possible  should  be  passed,  and  a 
stream  of  warm  water  forcibly  injected  with  a  large  bore 
syringe.  At  first  only  a  very  small  quantity  of  fluid 
should  be  injected,  and  then  allowed  to  flow  back  again ; 
as  the  clot  comes  away  more  and  more  fluid  may  be 
injected  each  time.  This  must  be  persisted  with  until 
all  the  clot  has  been  washed  out  of  the  bladder,  as  evi- 
denced by  the  absence  of  clots  in  the  water  coming  back 
from  it.  Some  styptic  solution  should  then  be  injected 
into  the  bladder  :  for  this  purpose  a  strong  solution  of 
hazeline  or  Ruspini's  styptic  is  recommended  ;  but  other 
styptics,  such  as  suprarenal  extract,  turpentine,  etc.,  may 
be  used  instead.  Styptics  having  a  caustic  action,  such 
as  liq.  ferri  perchlor.,  etc.,  must  not  be  used,  as  they  set 
up  cystitis. 

Of  course,  if  there  is  an  opening  into  the  bladder? 
either  through  the  perineum  or  above  the  pubes,  the  clot 
can  be  washed  out  much  more  easily  through  it.  And 
when  there  is  such  an  opening,  if  the  haemorrhage  will 
not  yield  to  i-typtics  and  hot  lotion,  the  bladder  may  be 
packed  with  strips  of  hnt  after  passing  a  tube  or  tubes 


Haemorrhage  after  Operations         69 

down  to  the  openings  of  the  ureters.  The  lint  should  be 
in  long  strips,  and  the  ends  left  outside  the  wound.  In 
cases  of  severe  haemorrhage  from  the  prostate  or  trigone 
the  bleeding  can  be  temporarily  controlled  by  passing 
one  finger  into  the  rectum  and  compressing  the  prostate 
and  trigone  against  the  back  of  the  pubes,  or  by  com- 
pressing the  bladder  bimanually  by  one  hand  above  the 
pubes  and  a  finger  in  the  rectum. 

HAEMORRHAGE  FROM  THE  Rectum. — This  is,  fortunately, 
a  rare  occurrence  with  the  present  improved  methods  of 
operating;  it  still,  however,  occasionally  follows  operations 
for  piles,  etc.  It  is  a  very  troublesome  complication,  not 
only  on  account  of  the  difficulty  of  stopping  it,  but  because 
a  large  amount  of  blood  may  be  lost  into  the  bowel  before 
there  is  any  external  evidence  of  its  presence.  The 
haemorrhage  usually  takes  place  after  the  bowels  have 
acted  for  the  first  time  following  the  operation,  and  is,  as 
a  rule,  due  to  the  slipping  or  premature  separation  of  a 
ligature.  The  bleeding  is  free,  and  is  accompanied  by  a 
considerable  amount  of  collapse.  The  bleeding  may, 
however,  occur  where  no  ligature  has  been  used.  In  a 
case  which  the  author  saw  recently,  a  haemorrhage  which 
might  have  been  fatal  and  which  necessitated  plugging 
the  rectum  occurred  three  weeks  after  the  operation  and 
a  week  after  all  the  ligatures  had  separated. 

It  is  well  to  remember  that  the  amount  of  blood  lost 
externally  is  no  indication  of  the  total  haemorrhage,  as 
the  rectum  and  sigmoid  may  be  filled  with  clot.  An 
anaesthetic  should  be  administered  and  the  sphincter 
dilated,  then,  after  emptying  the  bowel  of  clot  with  the 
finger  and  by  syringing  with  hot  water  an  attempt 
may  be  made  to  clip  the  bleeding-point  and  religature 
it.  To  facilitate  this  manoeuvre  the  wall  of  the  rectum 
above  the  bleeding-point  should  be  caught  with  a  pair 


7<^     The  After-Treatment  of  Operations 


of  pile  forceps  or  an  ordinary  clip,  and  drawn  down  so 
as  to  give  good  access  to  the  bleeding  spot.  Even  then 
it  is  often  by  no  means  an  easy  matter  to  control  the 
haemorrhage,  as  the  rectum  tends  to  lie  in  folds,  and  the 
bleeding  often  comes  from  a  surface  rather  than  a  point. 
If,  as  is  not  infrequently  the  case,  it  is  found  to  be 
impossible  to  control  the  haemorrhage  in  this  way,  the 
rectum  must  be  plugged. 

This  is  best  done  as  follows  :  A  piece  of  sterilized 
indiarubber  drainage-tube  about  3^  inches  long  and 
■^  inch  in  diameter  is  taken,  and  round  one  half  of  this 

a  strip  of  dry  gauze  or 
wool  is  wrapped,  so  as  to 
increase  its  diameter  by 
about  three  times.  The 
surface  of  the  gauze  is 
then  well  greased  with 
sterilized  vaseline,  and 
the  tube  is  inserted  into 
the  rectum,  with  the  big 
end  upwards.  The  por- 
tion of  the  tube  which 
projects  out  of  the  anus 
should  then  be  pulled  upon  so  as  to  bring  the  dilated 
part  down  against  the  bleeding  surface.  A  large  safety- 
pin  should  next  be  passed  through  the  end  of  the  tube 
about  i  inch  away  from  the  anus,  and  a  long  strip  of 
gauze,  which  has  been  previously  greased  with  vaseline, 
wrapped  round  and  round  the  tube  between  the  anus  and 
the  safety-pin.  Any  required  amount  of  pressure  can 
thus  be  exerted  upon  the  bleeding-point,  as  the  gauze 
wrapped  round  outside  pulls  down  the  tube  and  retains 
it  in  place  (see  diagram.  Fig.  15).  Another  method  of 
plugging  the  rectum  which  is  useful  in  cases  where  an 


Fig.  i= 


Hemorrhage  after  Operations         71 

anaesthetic  cannot  be  given  is  to  cut  a  finger-stall  out 
of  an  indiarubber  operating-glove,  and,  having  greased  it 
inside  and  out  and  having  inserted  one's  finger  into  it, 
pass  it  gently  into  the  rectum.  Then  withdraw  the 
finger  and  plug  the  inside  of  the  finger-stall  with  gauze, 
using  a  large  safety-pin  as  before  to  prevent  the  plug 
clipping  up  too  far  into  the  bowel. 

It  is  seldom  necessary  to  leave  the  plug  in  for  more 
than  forty-eight  hours.  After  its  removal  a  small  piece 
of  drainage  tube  may  be  left  in  the  bowel  to  give  warning 
should  any  further  bleeding  occur. 

In  cases  of  secondary  haemorrhage — i.e.,  when  bleeding 
occurs  a  week  or  more  after  the  operation,  and  is  due  to 
sloughing — no  attempt  should  be  made  to  catch  the 
bleeding-point  with  clips,  but  plugging  should  be  resorted 
to  at  once.  In  women,  haemorrhage  from  the  rectum 
can  be  temporarily  controlled  by  passing  a  finger  into 
the  vagina  and  compressing  the  rectal  wall  against  the 
sacrum. 

Bleeding  after  Incision  into  Inflamed  Tissues. — 
It  is  not  at  all  uncommon  for  rather  free  htemorrhage  to 
occur  after  incisions  have  been  made  into  inflamed  tissues, 
such  as  for  the  relief  of  tension  in  cellulitis,  etc.  The 
ends  of  any  small  vessels  that  may  have  been  divided  do 
not  contract,  but  are  held  open,  and,  in  consequence, 
bleeding  from  them  continues  for  some  time.  A  certain 
amount  of  bleeding  in  these  cases  is  advantageous,  as  it 
relieves  the  local  congestion.  If  it  continues  for  long, 
however,  something  may  have  to  be  done  to  stop  it. 
It  is  generally  useless  to  attempt  to  pick  up  the  bleeding- 
points,  as  the  tissues  are  often  so  rotten  that  they  give 
way  at  once-.  Elevation  of  the  part  and  the  application 
of  a  really  hot  fomentation  and  pressure  will  almost 
always  suffice  to  stop  the  bleeding.     Should  it  not   do 


72     The  After-Treatment  of  Operations 

so,  the  incisions  must  be  packed  with  strips  of  gauze  or 
lint,  and  firm  pressure  applied  with  cotton-wool  and 
bandages. 

When  severe  haemorrhage  occurs  from  a  wounded 
vessel  situated  in  rotten  or  gangrenous  tissues,  and  the 
vessel  cannot  be  picked  up  with  a  clip  owing  to  the 
tissues  tearing  away,  the  best  way  to  secure  the  vessel 
is  to  pass  a  hare-lip  pin  or  needle  through  the  tissues 
beneath  it,  and  then  compress  the  vessel  by  a  figure  of 
eight  made  with  silk  round  the  ends  of  the  pin — i.e., 
secure  the  vessel  by  acupressure.  This  is  also  the  best 
way  of  arresting  haemorrhage  from  an  artery  in  the 
base  of  an  ulcer  or  ulcerating  surface.  The  tissues  should 
be  under-pinned  on  the  proximal  side  of  the  bleeding- 
point. 

HAEMORRHAGE  FROM    THE   StUMP  AFTER  AmPUTATIOXS. 

— Recurrent  haemorrhage  after  an  amputation  will  usually 
stop  if  firm  pressure  is  applied  and  the  part  elevated. 
Should  it  not  do  so,  the  wound  must  be  reopened,  and 
any  bleeding-points  clipped  and  hgatared. 

Secondary  haemorrhage  after  an  amputation  is,  fortu- 
nately, a  very  rare  occurrence  now,  though  it  used  to  be 
common.  Ligature  of  the  main  vessel  above  has  been 
advised,  but  most  authorities  agree  that  it  is  better  to 
re-amputate  higher  up. 

Constitutional  Treatment  of  Patients  suffering 
from  Haemorrhage. 

Immediate  Treatment. — This  is  mainly  the  treat- 
ment of  shock,  which  is  gone  into  in  the  next  chapter. 

The  patient  should  be  freely  stimulated  if  all  the  bleed- 
ing-points have  been  properly  secured.  Liquor  is  strych- 
ninae  may  be  given  hypodermically  in  doses  of  from  5  to 


Haemorrhage  after  Operations         "]% 

lo  minims.  Brandy  or  whisky  may  be  given  ;  this  is  best 
done  by  giving  repeated  doses  of  from  |^  to  i  ounce  by 
the  rectum — or  mouth  if  there  is  no  danger  of  vomiting — 
or  alcohol  can  be  given  hypodermically  in  small  doses 
(lo  to  20  minims). 

Remote  Treatment.  —  Patients  who  have  suffered 
from  severe  haemorrhage  are  usually  very  anaemic,  and 
in  old  or  weakly  patients  this  condition  may  persist  for 
some  time.  In  children  and  young  adults  the  blood- 
forming  capacity  is  good,  and  they  soon  make  up  any 
deficiency.  In  order  to  assist  the  tissues  in  forming  new 
blood,  iron  in  some  form  or  another  should  be  given  until 
all  signs  of  anaemia  have  disappeared.  Port  wine  is  an 
excellent  remedy  in  these  cases,  and  3  to  6  ounces  should 
be  given  per  diem  unless  otherwise  contra-indicated. 
Patients  who  are  suffering  from  anaemia  due  to  loss  of 
blood  must  not  be  allowed  to  get  up  and  about  too  soon  ; 
they  must  be  made  to  go  very  gradually  at  first,  as  there 
is  great  danger  of  thrombosis  if  they  are  allowed  to  get 
up  too  quickly.  Massage  to  the  lower  limbs,  if  carried 
out  for  a  day  or  so  previous  to  their  getting  up,  will  do 
much  to  prevent  this  danger. 


CHAPTER  V 

SURGICAL    SHOCK 

Surgical  shock  is  a  condition  of  exhaustion  of  all  the 
vital  faculties,  which  is  liable  to  occur  after  any  severe 
injury  or  surgical  operation.  Before  the  discovery  of 
modern  aseptic  surgery  by  Lister,  the  two  great  dangers 
of  surgical  operations  were  sepsis  and  shock.  Thanks 
to  his  discovery,  the  danger  of  sepsis  has  now  been 
almost  eliminated  ;  but  it  was  not  until  comparatively 
recently  that  any  attempt  was  made  to  study,  from  a 
scientific  point  of  view,  the  shock  following  operations, 
or  to  iind  out  how  it  could  be  best  combated.  The  first 
real  scientific  researches  into  this  subject  were  made  by 
G.  W.  Crile  in  America.  The  publication  of  the  results 
of  his  researches  in  1897  ^^^'^  the  foundation  of  our 
modern  conception  of  what  is  really  meant  by  surgical 
shock.  Since  that  date  research  on  this  subject  has  been 
almost  continuous.  In  1905  the  author  of  this  book 
published  the  Hunterian  Lectures  delivered  at  the  Royal 
College  of  Surgeons,  on  the  '  Physiology  and  Surgical 
Treatment  of  Shock  and  Collapse.'  The  most  recent 
research  work  on  the  subject  is  a  book  just  published,  by 
G.  W.  Crile  and  W.  E.  Lower,  entitled  '  Anoci-Associa- 
tion,'  in  which  a  large  amount  of  very  valuable  experi- 
mental work  is  recorded,  and  it  may  now  be  said  that  the 
physiology  of  surgical  shock  is  no  longer  a  closed  book,  but 

74 


Surgical  Shock  75 

that  the  main  factors  in  the  causation  of  this  curious  con- 
dition are  well  known  and  understood.  The  greatest  credit 
is  due  to  Dr.  Crile  for  the  careful  and  thorough  manner  in 
which  his  experimental  work  has  been  carried  out,  for  no 
stone  has  been  left  unturned  and  no  corner  uninvestigated. 

It  is  obviously  impossible  to  give  a  complete  description 
of  the  physiology  of  shock  in  the  present  volume.  The 
reader  is,  however,  referred  to  the  works  mentioned  at 
the  end  of  this  chapter  for  further  information  on  this 
interesting  subject. 

The  symptoms  of  surgical  shock  must  be  familiar  to 
everyone  who  has  worked  in  the  hospital  wards  of  a  large 
hospital.  The  most  typical  picture  that  one  can  take  is 
perhaps  that  of  a  man  who  has  undergone  a  serious  and 
severe  operation  which  has  resulted  in  shock.  Previous 
to  the  operation  the  patient  presented  the  ordinary  ap- 
pearance of  a  healthy  human  being  (apart  from  the 
condition  for  which  the  operation  was  performed),  with 
a  good  colour,  normal  pulse,  and  muscles  which  re- 
sponded promptly  to  his  call.  If  we  examine  this  same 
patient  after  the  operation,  when  he  is  in  a  condition  of 
shock,  we  find  that  the  skin  is  pale^  covered  with  sweat, 
and  feels  cold  to  the  ejcajpLnijogJiand  ;  the  pulse  is  rapid 
and  so  slight  as  to  be  hardly  perceptible  except  in  the 
larger  arteries  ;  the  temperature  is  subnormal,  and  the 
respirations  rapid  and  shallow ;  the  eyes  have  a  glazed  and 
anxious  appearance  ;  and  although  the  patient  is  quite 
conscious,  he  is  incapable  of  doing  anything  for  himself, 
and  is  only  just  able  to  answer  questions.  There  is 
generally  a  certain  amount  of  restlessness,  and  the  face 
expresses  extreme  exhaustion  and  a  fear  of  impending 
dissolution,  while  the  skin  appears  to  have  shrunk  over 
the  facial  bones.  The  patient  complains  of  thirst,  and  is 
constantly  asking  for  something  to  drink.     He  is  hardly 


76     The  After-Treatment  of  Operations 

able  to  lift  his  head  from  the  pillow,  and  his  muscles  are 
in  a  condition  of  complete  relaxation,  as  if  he  were  utterly 
exhausted  after  running  a  long  race.  Food  cannot  be 
digested,  and  all  the  functions  are  more  or  less  inhibited. 
Thus,  the  mouth  is  dry  owing  to  a  lack  of  salivary  secre- 
tion, there  is  very  little  urine  passed,  and  digestion  has 
ceased  owing  to  the  lack  of  digestive  juices ;  the  most 
marked  feature  of  this  condition,  however,  is  the  great 
lowering  of  the  blood-pressure.  The  blood-pressure  of  a 
normal  man  is  120  to  130  millimetres  of  mercury,  as  mea- 
sured by  a  sphygmometer.  In  the  condition  of  shock  we 
have  been  describing  the  pressure  will  be  found  to  have 
fallen  to  60  millimetres  of  mercury,  or  even  lower.  The 
blood  has  accumulated  in  the  large  vessels  of  the  abdomen, 
and  if  the  patient  were  sat  up  he  would,  in  most  cases,  im- 
mediately collapse  and  become  unconscious,  owing  to  the 
anaemia  of  the  brain  caused  by  the  blood,  under  the  force 
of  gravity,  flowing  out  of  it  to  the  lower  parts  of  the  body. 
This  condition,  which  sometimes  follows  severe  operation 
or  other  injuries,  is  a  most  interesting  physiological  prob- 
lem, and  the  factors  producing  this  curious  condition  have 
been  very  carefully  investigated.  The  following  is  a  brief 
outline  of  the  more  important  factors  concerned  in  its 
production. 

Physiologry  of  Shock. 

In  a  normal  human  being  the  pressure  of  the  blood  in 
the  vessels  of  the  various  parts  of  the  body  is  maintained 
at,  or  about,  a  constant  pressure  (roughly  between  120 
and  130  millimetres  of  mercury)  by  the  contraction  or 
relaxation  of  the  muscular  walls  of  the  arteries  and 
arterioles,  while  the  circulation  through  the  vessels  is 
maintained  by  the  action  of  the  heart.  It  is  obvious  that 
if  there  were  not  some  means  of  controlling  the  pressure 


Surgical  Shock  j'j 

within  the  vessels,  constant  and  disastrous  changes  would 
occur  in  the  distribution  of  the  blood  as  the  result  of 
changes  of  position,  owing  to  the  force  of  gravity.  Thus, 
in  the  erect  position  the  blood  would  tend  to  flow  to  the 
feet  and  away  from  the  brain,  and  so  produce  uncon- 
sciousness by  anaemia  of  the  brain-cells.  In  a  healthy 
person  the  pressure  of  the  blood  is  maintained  by  means  of 
certain  centres  in  the  brain  called  the  vasomotor  centres. 
These  centres  not  only  keep  the  pressure  within  the  larger 
vessels  at  a  more  or  less  constant  figure,  but  also  control 
the  amount  of  blood  in  any  one  part  of  the  body  at  a  time, 
and  by  so  doing  adapt  the  supply  of  blood  to  the  require- 
ments of  the  particular  organ  which  is  most  in  need  of 
an  increased  supply  of  blood  at  any  one  time.  If  these 
centres  in  the  brain  cease  to  act,  the  blood  immediately 
accumulates  in  the  splanchnic  area,  and  a  great  fall  in 
general  blood-pressure  occurs.  •  Thus,  experimentally,  if 
the  vasomotor  centres  in  the  brain  are  cocainized,  a  great 
fall  in  general  blood-pressure  results,  and  the  animal 
passes  into  a  condition  similar  to  that  of  surgical  shock. 
A  similar  condition  results  from  damage  to  the  vasomotor 
centres,  or  from  section  of  the  spinal  cord.  Experimental 
investigation  has__proved_that  the  condition  of  surgical^ 
shock  is  the_r£5ult__of  exhaustion  of  the  great  centres  in 
the  central  nervous  system,  which  control  the  vital  Junc:: 
tions  of  the 'body,  more  parti  cularly~t  hose  centres~which_ 
directly  control  the  maintenance  of  a  normal  circulation 
throughout  the  bo^7~siicB~asthe  vasomotor  and  the 
respiratory  cenfres,  although  all  ttie  cenTresTnTthe  brain^ 
arejnore[or  less  affectedT 

The  whole  of  the  surface  of  the  body  and  some  of  the 
deeper  parts  are  supplied  with  nerve-endings,  or  '  noci- 
ceptors,' whose  function  it  is  to  send  messages  to  the  brain 
when  they  are  stimulated.     Stimuli  are  of  two  kinds — 


78      The  After-Treatment  of  Operations 

those  of  ordinary  sensation,  which  might  be  described  as 
messages  conveying  information  to  the  brain-centres,  and 
useful  in  assisting  the  ordinary  functions  of  the  body; 
and,  secondly,  stimuli  of  pain,  conveying  messages  to  the 
brain  when  damage  is  being  done  to  that  particular  part 
of  the  body,  and,  if  we  may  say  so,  asking  for  assistance. 
The  immediate  result  of  painful  stimuli  is  motor  activity, 
in  order  to  get  away  from,  or  remove,  the  cause  of  the 
pain.  If  the  person  or  animal  is  under  an  anaesthetic, 
this  motor  activity  cannot  be  manifested  in  movement  of 
muscles  ;  but  there  is,  nevertheless,  expenditure  of  energy 
within  the  brain.  This  can  be  seen  experimentally  by 
direct  increase  in  the  blood-pressure,  increased  frequency 
of  the  pulse,  and  increased  frequency  of  the  respiration 
as  the  result  of  painful  stimuli. 

Dr.  Crile  has  recently  gone  much  further,  and  has  been 
able  to  show  that  actual  microscopic  changes  occur  in  the 
cells  of  the  cortex  of  the  brain  as  a  result  of  stimuli  reach- 
ing the  centres  from  the  nerve-endings  in  the  skin.  He 
has  been  able  to  show  that  if  stimuli  of  a  painful  character 
from  the  nerve-endings  on  the  skin  pass  up  the  afferent 
nerves  in  sufficient  quantity  and  severity,  demonstrable 
lesions  occur  in  the  cells  of  the  brain,  suprarenals,  and 
the  liver.  There  are  certain  organs  in  the  body,  among 
which  are  the  brain,  the  thyroid,  the  suprarenals,  the 
liver,  and  the  muscles,  whose  function  is  that  of  convert- 
ing latent  into  kinetic  energy  in  response  to  adaptive 
stimulation.  In  response  to  environmental  stimuli  of 
any  sort,  these  organs  convert  latent  energy  into  motion, 
or  into  heat.  As  the  result  of  long-continued  painful 
stimuh,  certain  changes  can  be  demonstrated  to  take 
place  in  the  cells  of  these  organs.  Thus,  if  shock  of  a 
severe  character  is  experimentally  produced  in  a  normal, 
anaesthetized  dog,  changes  in  the  cells  of  the  brain  cortex 


Surgical  Shock  79 

and  cerebellum  are  found  to  take  place  as  a  result. 
These  changes  are — (i)  chromatolysis  ;  (2)  alteration  in 
the  nucleus-plasma  relation  ;  (3)  rupture  of  the  nuclear 
and  cell  membranes  ;  (4)  in  extreme  cases,  disintegration 
of  the  cell  itself.  These  changes  in  the  cortical  cells 
occur  as  the  result  of  long-continued  painful  stimuli, 
such  as  would  be  caused  by  a  severe  and  protracted 
operation  or  a  severe  traumatism ;  but  it  has  also  been 
demonstrated  that  such  emotions  as  fear  and  anger,  if 
prolonged  and  intense,  will  likewise  produce  similar 
changes  in  the  brain-cells  which  are  indistinguishable 
from  those  produced  by  shock.  Severe  local  infections, 
such  as  peritonitis,  will  also  cause  similar  changes. 

As  a  result  of  clinical  experience  we  know,  of  course, 
the  extremely  important  part  played  by  fear  and  terror 
in  the  production  of  shock  when  associated  with  trauma. 
It  seems  certain  that  the  centres  in  the  brain,  the 
muscles,  the  liver,  suprarenals,  and  probably  many  other 
of  the  internal  secretory  glands,  act  together  as  a  system 
to  preserve  the  integrity  of  the  body  as  a  whole.  This 
system  has  been  termed  by  Crile  the  'kinetic  system,' 
its  object  being  to  protect  the  body  against  harmful 
affects  from  outside  agents.  The  whole  of  this  system 
suffers  together  in  conditions  such  as  shock,  and  shows 
demonstrable  changes  in  its  cells. 

In  recent  years  a  good  many  theories  of  shock  have 
been  propounded  with  a  view  to  showing  that  the  pheno- 
mena of  shock  are  due  to  changes  in  the  contents  of  the 
blood,  or  to  the  noxious  products  of  metabolism  cir- 
culating in  the  blood-stream.  It  is  obvious  that  the 
correctness  or  otherwise  of  any  such  theory  is  easily  put 
to  the  proof  by  experiment,  and  for  many  years  the 
author  has  wanted  to  perform  such  an  experiment  with 
a  view  to  testing  once  and   for  all    the  correctness  of 


8o      The  After-Treatment  of  Operations 

such  theories.  Such  experiments  are,  however,  difficult 
to  perform  in  this  country,  and  he  has  never  been  able  to 
carry  out  the  experiment.  Recently  Dr.  Crile  has  per- 
formed this  experiment  with  complete  success.  The 
experiment  consists  in  crossing  the  circulation  of  two 
dogs.  It  is  obvious  that  if  the  circulation  of  two  animals 
can  be  united  in  such  a  way  that  the  blood  circulates 
through  both  of  them,  and  if  one  of  these  animals  is  put 
into  a  condition  of  shock,  then,  provided  that  the  cause 
of  shock  is  due  to  any  change  in  the  gaseous  or  other 
contents  of  the  blood,  both  animals — the  shocked  animal 
and  the  other  animal — will  suffer  alike  ;  but  if  shock  is 
due  to  damage  or  exhaustion  of  nerve  -  centres  by  re- 
peated stimuli,  as  Dr.  Crile  and  the  present  writer  believe, 
then  the  non-shocked  animal  will  be  quite  unaffected. 

Dr.  Crile  performed  this  experiment  by  anastomosing 
the  proximal  end  of  one  carotid  artery  of  Dog  A  with 
the  distal  end  of  the  corresponding  carotid  artery  of 
Dog  B,  and  one  jugular  vein  of  Dog  A  with  the  corre- 
sponding vein  of  Dog  B.  The  dogs  were  as  nearly  as 
possible  alike,  and  were  both  under  an  equal  amount  of 
anaesthesia.  Dog  A  was  subjected  to  traumatism 
sufficient  to  produce  shock.  Both  animals  were  then 
killed,  and  their  brains  examined.  It  was  found  that 
the  typical  changes  in  the  cells  of  the  brain  cortex  were 
present  in  Dog  A,  while  they  were  completely  absent 
in  Dog  B.  The  result  of  this  experiment  proves  that 
gaseous  or  other  changes  in  the  blood  cannot  be  the 
primary  cause  of  shock,  and  it  therefore  disposes  of  the 
acapnia  theory  of  Yendall  Henderson. 

It  is  obvious  that  if  an  operation  is  to  be  performed  in 
such  a  way  that  no  shock  shall  result,  tw'o  factors  are 
necessary:  (i)  All  stimuli  of  a  painful  character  must  be 
prevented  so  far  as  possible  from  reaching  the  brain  from 


Surgical   Shock  8i 

the  area  of  operation  ;  and  (2)  the  patient  must  be  pro- 
tected from  the  harmful  effects  of  fear,  terror,  etc.,  which 
might  be  caused  by  the  performance  of  the  operation  or 
its  anticipation.  Further,  if  these  two  conditions  can  be 
fulfilled  there  should  be  no  shock  resulting  from  an 
operation,  unless  there  has  been  severe  haemorrhage. 

Different  parts  of  the  body  have  different  shock-pro- 
ducing properties  when  operated  upon,  and  it  is  important 
that  these  should  be  known,  so  that  special  care  may  be 
taken  when  operating  upon  such  parts. 

The  Relation  between  the  Region  operated  upon  and  the 
Shock  produced. — It  appears  that  operations  upon  the 
abdominal  contents  and  visceral  peritoneum,  and  opera- 
tions upon  the  male  generative  organs,  produce  the  most 
profound  shock  as  a  general  rule.  In  the  abdomen  the 
severity  of  the  shock  produced  is  in  proportion  to  the 
distance  of  the  part  operated  upon  from  the  pelvis,  the 
shock  being  most  severe  after  operations  in  the  neighbour- 
hood of  the  stomach,  pylorus,  and  duodenum. 

In  the  extremities  the  amount  of  shock  caused  by 
operation  is  in  direct  proportion  to  the  nerve-supply  of 
the  part — that  is,  to  the  area  of  skin  and  muscle  injured 
and  the  relative  number  of  nerve-endings  in  that  area. 
Thus,  a  crush  of  the  paw  of  a  dog  will  cause  more  pro- 
nounced shock  than  amputation  of  the  limb  high  up. 
Crile  states  that  in  animals  subjected  to  extensive 
removal  of  integument,  shock  was  induced  with  a 
rapidity  proportional  to  the  area  exposed,  and  its  depth 
corresponded  to  the  duration  of  the  exposure. 

Recent  experimental  work  carried  out  by  Dr.  Symes 
and  the  present  writer  has  proved  that  injury  or  inter- 
ference with  the  parietal  peritoneum  or  mesentery  will 
produce  shock,  while  similar  manipulation  of  the  visceral 
peritoneum  has  no  effect. 

6 


82      The  After-Treatment  of  Operations 
Collapse. 

Collapse  is  a  very  similar  condition  to  shock,  but  with 
certain  marked  differences.  Collapse,  unlike  shock, 
occurs  suddenly,  and  is  accompanied  by  a  great  and 
sudden  fall  in  blood-pressure,  often  with  resulting  anaemia 
of  the  brain  and  unconsciousness.  It  is  due  to  a  sudden 
paralysis  of  the  kinetic  system,  or,  in  other  words,  of  the 
centres  of  the  brain  and  cord  controlling  the  maintenance 
of  the  blood-pressure.  It  differs  from  shock  in  that  it  may 
be  successfully  treated  by  means  of  stimulants.  Since, 
however,  the  important  cause  of  the  trouble  is  the  sudden 
fall  in  blood-pressure,  the  obvious  indication  is  to 
support  the  blood-pressure,  and  the  brain  and  heart,  by 
putting  the  patient  into  a  recumbent  position,  or  with 
the  head  down,  to  drive  the  blood  out  of  the  limbs  and 
abdomen  by  pressure,  while  at  the  same  time  stimulants 
are  administered  or  the  bloodvessels  transfused  in  order 
to  combat  the  lowered  pressure  in  the  vessels. 

The  condition  following  severe  haemorrhage  differs 
from  both  shock  and  collapse  in  that  the  centres  in  the 
brain  are  not  at  first  affected,  the  falling  blood-pressure 
being  due  to  an  actual  loss  of  fluid.  If,  however,  the 
haemorrhage  has  been  severe  and  the  lowered  pressure 
has  persisted  for  some  time  without  relief,  a  condition  of 
true  shock  may  supervene.  The  obvious  treatment  for 
severe  haemorrhage  is  transfusion,  preferably  with  blood 
from  another  subject,  but  failing  this,  with  a  physiological 
salt  solution. 

The  Treatment  of  Shock. 

It  will  be  obvious  from  the  foregoing  description  of 
the  physiology  of  shock  that  it  is  possible  to  prevent 
shock  from  occurring  as  the  result  of  an  operation,  and 


Surgical  Shock  83 

that  the  best  way  of  protecting  one's  patient  from  this  con- 
dition is  to  so  perform  the  operation  that  shock-producing 
factors  will  be  absent.  In  fact,  post-operative  shock  is 
now,  or  soon  will  be,  as  much  a  reflection  on  the  surgical 
technique  of  the  surgeon  performing  the  operation  as  is 
sepsis  in  the  wound  ;  that  is  to  say,  that  when  an  opera- 
tion can  be  performed  under  circumstances  carefully 
chosen  and  selected  by  the  surgeon  beforehand,  and  with 
the  necessary  proper  assistance  and  preparation,  surgical 
shock  should  not  result  from  any  operation,  provided  the 
surgeon  is  sufficiently  skilled  in  the  technique  of  oper- 
ating. 

Methods  of  preventing-  Shock. 

The  ideal  method  of  preventing  shock  is  so  to  anaes- 
thetize the  patient  that  no  afferent  impulses  of  a  painful 
or  harmful  character  can  reach  the  brain-centres.  It  has 
been  shown  that  in  order  to  secure  such  conditions  all  the 
nerves  passing  from  the  area  of  operation  must  be  tem- 
porarily blocked  by  a  local  anaesthetic,  so  that  no  impulses 
can  pass  from  the  operative  field,  and  at  the  same  time 
the  higher  brain-centres  must  be  further  protected  from 
outside  impulses  by  a  preliminary  narcotic  and  suitable 
general  anaesthetic  to  the  point  of  unconsciousness,  This 
method  of  performing  shockless  operations  has  been  very 
carefully  worked  out  by  Dr.  Crile  and  others,  and  is  now 
interesting  many  surgeons.  This  method  has  proved  that 
in  most  operations  it  is  possible  by  means  of  the  correct 
technique  to  be  absolutely  certain  that  no  shock  will 
follow  the  operation,  and  no  doubt  in  time  and  with 
increased  knowledge  it  will  be  possible  to  apply  this 
method  to  all  operations.  The  exact  technique  of  the 
method  cannot  be  described  here  for  want  of  space,  but 
it  will  be  found  in  Dr.  Crile's  textbook. 


84     The  After-Treatment  of  Operations 

There  are  certain  factors  in  an  operation  which  are 
particularly  liable  to  produce  shock,  and  by  taking  care 
to  avoid  these,  much  may  be  done  to  prevent  its  occur- 
rence. Thus,  tearing  and  crushing  tissues  causes  much 
more  shock  than  cutting  with  a  sharp  knife.  The  rough 
use  of  retractors,  dragging  or  pulling  on  the  intestine, 
and,  in  fact,  roughness  of  any  kind,  should  be  avoided. 
Again,  certain  areas  require  particularly  careful  handling, 
as,  owing  to  the  distribution  of  the  nerves  in  these  areas, 
shock  is  especially  liable  to  result  from  interference  with 
them.  Such  areas  are  the  upper  region  of  the  abdomen 
and  diaphragm,  the  extremities  of  the  limbs,  the  neigh- 
bourhood of  the  anus,  and  the  parts  round  the  mouth  and 
larynx. 

One  must  also  realize  that  emotions  such  as  fear  and 
terror  have  a  powerful  effect  in  producing  shock,  and  in 
accelerating  it  when  combined  with  an  operation,  so  that 
patients  who  are  highly  nervous  about  themselves  and 
dread  an  operation  are  much  more  liable  to  suffer  from 
shock.  For  these  reasons,  the  patient  must  be  protected 
by  every  possible  means  against  such  influences.  Care- 
ful preparatory  treatment,  avoiding  all  details  in  the  prep- 
aration which  may  tend  to  frighten  the  patient,  and  the 
administration  of  a  preliminary  narcotic,  such  as  morphia, 
and  atropine  or  scopolamine,  are  valuable  agents.  The 
author's  practice  is  to  administer  from  |  to  ^  of  mor- 
phia combined  with  -^-^  of  atropine  hypodermically 
about  an  hour  before  the  operation.  An  important 
point  also,  which  is  often  neglected,  is  to  see  that 
when  the  patient  enters  the  operating-room  no 
time  is  wasted  in  getting  him  immediately  under  the 
anaesthetic.  To  keep  a  patient  waiting  even  two 
minutes  while  the  anassthetist  is  getting  ready  is  of 
much   more   consequence    than   many   people   suppose. 


Surgical  Shock  85 

Complete  quiet  during  the  period  of  induction  of  anaes- 
thesia is  also  an  important  factor. 

Pain  and  discomfort  after  the  operation  are  potent 
causes  of  shock,  so  that  a  patient  who  was  not  suffering 
from  shock  when  he  left  the  operating-table  may  be  found 
deeply  affected  by  shock  some  hours  later  if  careful 
means  have  not  been  taken  to  prevent  painful  impulses. 
Everything  should  be  done  to  relieve  pain,  and  when 
shock  is  feared  a  narcotic,  such  as  morphia  or  heroin, 
should  be  administered  at  regular  intervals  in  sufficient 
quantities  to  keep  the  patient  free  from  pain  and  discom- 
fort. The  rapid  increase  in  the  pulse  and  respiration  is  a 
sign  calling  for  the  administration  of  a  narcotic. 

Treatment  of  Shock. 

When  a  patient  is  seen  who  is  already  suffering  from 
shock,  the  first  thing  to  do  is  to  remove  the  cause  of  this 
condition,  if  still  operative — that  is  to  say,  if  the  patient  is 
in  pain,  morphia  or  heroin  should  be  administered  hypo- 
dermically  in  sufficient  doses  to  shut  off  immediately  all 
painful  impulses  and  produce  rest  and  quiet.  This 
should  be  done  before  any  other  treatment  is  given. 

Warmth. — The  patient  should  be  kept  warm  with 
blankets  and  hot  bottles,  but  care  must  be  taken  not  to 
overdo  this ;  the  patient  should  never  be  kept  in  a  con- 
dition of  profuse  perspiration,  as  this  will  tend  to  greatly 
increase  the  shock.  Although  it  is  important  to  maintain 
the  body  temperature,  at  the  same  time  much  heat  will 
cause  dilation  of  the  superficial  vessels,  and  when  this 
occurs  it  means  a  still  greater  loss  of  blood  to  the 
essential  circulation. 

Position. — The  position  of  the  patient  is  of  great 
importance  in  treating  shock.  The  best  position  to  place 
the  patient  in,  is  with  the  foot  of  the  bed  so  raised  that 


86     The  After-Treatment  of  Operations 

the  abdomen  is  on  a  higher  level  than  the  thorax  and 
head.  This  tends  to  prevent  the  blood  from  accumulating 
in  the  abdomen  and  lower  limbs,  and  helps  the  blood  to 
flow  from  the  great  veins  into  the  heart.  The  foot  of 
the  bed  should  be  raised  on  blocks  a  foot  or  more  in 
height,  and  the  patient  should  not  have  a  pillow  under 
the  head. 

Bandagins:  the  abdomen,  rapidly  and  effectuall}'  raises 
the  general  blood-pressure,  and  may  be  tried  if  there  is 
no  serious  centra-indication  to  its  use  ;  since  it  tends  to 
embarrass  the  respiration  care  should  be  taken  to  see 
that  the  thorax  is  free  to  move,  and  is  not  pressed  upon 
by  heavy  bedclothes,  etc.  Bandaging  the  extremities  is 
also  effectual  in  raising  the  blood-pressure,  and  is  a 
useful  way  of  treating  shock  in  suitable  cases.  The 
limbs  should  be  tirmly  bandaged  all  the  way  up  "snth 
some  elastic  bandage,  such  as  flannel  or  domet.  The 
bandages  must  be  put  on  carefully  so  that  there  are  no 
creases,  and  must  not  be  left  on  for  long,  or  they  vi-ill  do 
harm  by  cutting  off  the  blood-supply  to  the  limbs. 

Stimulants. — These  are  worse  than  useless  in  the 
treatment  of  shock.  ]\Iany  cases  of  shock  can  easily  be 
rendered  much  more  serious  by  stimulation.  It  must  be 
remembered  that  the  cause  of  the  condition  is  exhaustion 
of  the  great  nerve-centres,  and  that  stimulation  increases 
this  exhaustion  and  does  not  give  the  centres  time  to 
recover.  Again,  if  the  heart  be  stimulated  while  the 
blood-pressure  is  still  so  low  that  the  great  venous  trunks 
passing  to  the  right  auricle  contain  only  a  small  amount 
of  blood  with  which  to  supply  it,  the  heart  will  only 
exhaust  itself  by  beating  more  forcibly  mthout  being 
able  to  raise  the  blood-pressure  or  improve  the  circula- 
tion, except  momentarily.  And  to  stimulate  the  heart 
to  increased  action  when  it  has  nothing  to  work  on  will 


Surgical  Shock  87 

only  have  the  effect  of  hastening  the  time  when  it  must 
fail.  It  is  true  that  an  injection  of  strychnine  will 
improve  the  pulse  for  a  time,  but  it  does  so  by  forcing 
the  already  exhausted  nerve-centres  into  action,  and  this 
will  be  followed  by  further  exhaustion  of  these  centres 
as  soon  as  the  effect  of  the  strychnine  has  passed  off. 
Again,  it  has  been  repeatedly  proved  by  experiment,  and 
is  a  well -observed  clinical  fact,  that  stimulants  ad- 
ministered while  the  patient  is  in  a  condition  of  shock 
are  often  not  eliminated,  but  remain  in  the  system,  so 
that  when  the  shock  passes  off"  the  combined  effect  of 
all  the  stimulants  administered  will  be  produced,  with 
perhaps  a  fatal  result.  This  is  particularly  the  case  with 
strychnine. 

It  has  recently  been  proved  by  a  series  of  experiments 
upon  animals  that  the  administration  of  strychnine  in 
repeated  doses  to  a  normal  animal  will  cause  shock  by 
overstimulation  of  the  vaso-motor  centres  and  consequent 
exhaustion.  In  all  degrees  of  shock  the  administration 
of  strychnine  caused  the  animals  to  sink  into  a  deeper 
degree  of  shock  as  soon  as  the  first  effects  of  the  adminis- 
tration had  passed  off.  These  facts  seem  to  be  well 
supported  by  clinical  observation,  and  it  follows  that 
strychnine  is  not  only  useless,  but  absolutely  harmful,  in 
the  treatment  of  shock.  In  collapse,  on  the  other  hand, 
strychnine  may  be  of  service,  as  the  vaso-motor  centres 
are  not  exhausted.  Even  in  the  collapse  following  a 
severe  haemorrhage,  strychnine  though  it  may  do  good, 
is  not  so  useful  as  transfusion,  which  directly  treats  the 
cause  of  the  collapse. 

Saline  Infusion. — The  obvious  indication  in  treating 
shock  is  to  raise  the  blood-pressure  as  near  as  possible  to 
the  normal  level,  and  to  keep  it  there  until  the  vasomotor 
centres  have  recovered  sufficiently  to  maintain  the  pres- 


88     The  After-Treatment  of  Operations 

sure  at  or  about  the  normal.  The  most  certain  and 
rapid  method  we  know  of  raising  the  blood-pressure  is 
that  of  saline  infusion  into  the  bloodvessels.  Unfortu- 
nately, it  has  been  proved  by  experiment,  and  confirmed 
by  clinical  observation,  that  the  pressure  can  only  be 
maintained  for  a  short  time  by  this  method  ;  and  although 
it  will  raise  the  pressure  rapidly  and  quickly  if  the  shock 
is  severe,  continued  intravenous  or  subcutaneous  infusion 
will  merely  result  in  the  water-logging  of  the  tissues,  and 
the  pressure  will  slowly  fall  back. 

The  only  form  of  transfusion  which  is  permanently 
effective  is  human  blood  from  another  patient.  This  method 
is  difficult  and  quite  inapplicable  in  most  cases.  It  doeo 
not  follow  that  infusion  with  physiological  salt  solution  is 
useless.  It  often  enables  us  to  tide  over  a  crisis,  and  gives 
the  patient  the  chance  of  recovery  that  is  alone  necessary. 
It  is  useless,  however,  to  repeat  it  for  any  length  of  time, 
and  other  methods  must  be  found. 

The  fluid  should  not  be  allowed  to  flow  in  too  quickly, 
and  it  should  be  kept  warm  (at  blood  temperature). 
There  is  generally  a  very  marked  improvement  in  the 
pulse  and  general  condition  as  soon  as  transfusion  is 
started  ;  this  must,  however,  not  be  taken  as  an  indication 
that  the  transfusion  can  be  stopped,  but  the  fluid  should  be 
allowed  to  flow  in  slowly  until  about  2  or  3  pints  have 
been  injected,  and  then  the  patient  should  be  watched 
for  a  time  to  see  if  the  blood-pressure  is  sustained. 

Method  of  performing  Transfusion. — The  best  apparatus 
for  the  purpose  is  about  2  feet  of  rubber  tubing,  to  one 
end  of  which  a  glass  funnel  is  attached,  and  to  the  other 
a  glass  cannula ;  the  cannula  should  taper  to  a  narrow 
point,  and  should  have  a  slight  bend  in  it.  The  cannula 
must  be  tied  into  the  end  of  the  tubing  before  com- 
mencing the  operation,     A  very  good  cannula  can  be 


Surgical  Shock 


89 


made  by  using  the  needle  of  an  exploring  syringe ;  it 
has  the  advantage  that  it  can  be  very  rapidly  introduced 
into  a  vein  without  even  a  preliminary  incision  being 
made  in  the  skin,  and,  in  addition,  it  can  be  introduced 
into  a  much  smaller  vein  than  the  glass  cannula  ;  and  this 
is  of  importance,  as  in  some  patients  the  veins,  even  such 
veins  as  the  median  basilic,  are  so  small  that  it  is  almost 
impossible  to  get  an  ordinary  glass  cannula  into  them. 

Introducing  the  Cannula.  —  A  bandage  should  first  be 
tied  round  the  upper  arm  to  make  the  veins  prominent ; 
then,  any  large  vein  being 
chosen  (this  will  usually 
be  the  median  basilic),  an 
incision  is  made  over  it 
and  the  vein  exposed.  A 
double  loop  of  silk  or  cat- 
gut is  then  passed  beneath 
the  vein  with  an  aneurism 
needle,  and  the  thread  is 
divided  so  that  there  is  a 
double  ligature  round  the 
vein.  The  lower  of  these 
ligatures  is  then  tied  up 
so  as  to  shut  off  the  vein 
below ;  the  other  is  held  up  by  the  surgeon  so  that 
the  vein  is  steadied  in  the  loop.  Next,  a  longitudinal 
incision  is  made  into  the  vein  with  the  point  of  the 
knife,  the  cannula  is  slipped  into  it,  and  the  upper 
ligature  tied  over  the  point  so  as.  to  fix  it  in  the  vein. 
Before  introducing  the  cannula,  the  surgeon  should 
see  that  the  whole  of  the  rubber  tubing  and  cannula 
are  full  of  fluid,  and  that  there  are  no  air-bubbles  in  the 
apparatus. 

If  the  needle  of  an  exploring  syringe  is  used  instead  of 


Fig. 


16. — Author's  Apparatus 
FOR  Intravenous  Infusion 
WITH  Adrenalin. 


90     The  After-Treatment  of  Operations 

the  glass  cannula,  it  can  simply  be  stabbed  through  the 
skin  into  the  vein  in  a  direction  towards  the  heart. 

The  best  solution  to  use  for  intravenous  infusion  is  a 
physiological  solution  such  as  the  following : 

R   NaCl          -  .            .            .           .  o-g. 

Potassii  chloras  ....  o'03. 

Calcii  chloridum  -            .            -            .  o'oi. 

Aqua           -  .             .             .             .  100-00. 

Messrs.  Burroughs  Wellcome  and  Co.  also  supply 
'  soloids,'  which  when  dissolved  in  water  make  a  physio- 
logical solution  ('  Soloid '  Sal.  Comp.). 

When  no  such  solution  is  obtainable,  a  fairly  satis- 
factory solution  can  be  made  by  adding  a  teaspoonful  of 
common  salt  to  i  pint  of  water.  The  solution  should 
be  boiled  to  sterilize  it,  and  then  cooled  down  to  about 
iio°  F.  The  right  temperature  may  be  roughly  esti- 
mated in  cases  of  emergency  by  the  surgeon  putting 
his  fingers  into  the  solution  ;  he  should  be  able  to  just 
bear  his  fingers  in  it  with  comfort.  In  an  emergency 
also,  when  it  is  necessary  to  waste  as  little  time  as 
possible,  the  fluid  need  not  be  sterilized,  but  common 
tap-water  may  be  used,  to  which  sufticient  boiling  water 
from  the  kettle  has  been  added  to  raise  it  to  the  desired 
temperature.  In  carrying  out  the  transfusion,  the  fluid 
should  be  allowed  to  flow  in  slowly,  and  if  there  are  any 
signs  of  dyspnoea  at  any  time  after  the  fluid  has  been 
running  in,  the  transfusion  must  be  stopped  until  this  has 
passed  off,  when  it  can  again  be  allowed  to  flow  in. 
Some  time  should  be  occupied  in  introducing  the  fluid, 
and  thirty  minutes  for  the  introduction  of  3  pints  is 
about  the  average  time  necessary :  2  or  3  pints  of  fluid 
should  be  allowed  to  flow  in,  and  then  the  cannula  may 
be  removed  and  the  wound  sewn  up  ;  or  the  cannula  may 
be  left  in,  and  the  rubber  tube,  after  being  clipped,  can 


Surgical  Shock  91 

be  wrapped  round  the  arm  so  that  it  is  all  ready  for  use 
again.  All  that  is  then  necessary  in  order  to  retransfuse 
is  to  unwrap  the  tube,  refix  the  glass  funnel,  and  remove 
the  clip.  It  might  be  supposed  that  there  is  a  danger  of 
the  blood  clotting  in  the  cannula  and  vein,  and  this  clot 
being  swept  into  the  circulation  by  the  next  lot  of  fluid 
used  for  transfusion.  This  is,  however,  not  the  case,  as 
the  cannula  and  vein  remain  full  of  water.  As  already 
mentioned,  the  addition  of  adrenalin  or  hemesine  to  the 
infusion  fluid  in  suitable  quantities  greatly  increases  the 
value  of  infusion. 

It  will  be  as  well  to  mention  here  that  rigors  some- 
times occur  after  transfusion  of  normal  salt  solution  or 
even  of  water.  They  usually  come  on  about  twenty 
minutes  or  half  an  hour  after  the  transfusion ;  they  are 
not  accompanied  by  any  rise  of  temperature,  and  soon 
pass  off  without  doing  any  harm.  What  the  cause  of 
them  is  it  is  very  difficult  to  say ;  that  they  are  not  due 
to  the  accidental  introduction  of  septic  matter  or  other 
poison  into  the  circulation  is  certain,  as  beyond  the  rigors 
no  other  bad  effects  follow,  and  they  occur  however  care- 
fully the  solution  and  instruments  are  sterilized.  They  do 
not  apparently  occur  if  physiological  solutions  are  used. 

Rigors  more  commonly  follow  transfusion  in  men  than 
in  women,  and  do  not  occur  except  in  a  comparatively 
small  number  of  cases.  Dyspnoea  is  said  to  follow  trans- 
fusion occasionally  ;  this  occurs  when  the  fluid  is  injected 
too  quickly  into  the  circulation,  and  is  due  to  sudden 
dilution  of  the  blood  in  the  lungs.  It  does  not  take  place 
if  the  fluid  is  injected  slowly  so  that  it  is  able  to  mix  with 
the  blood  before  passing  into  the  lungs.  If  it  should 
occur,  the  injection  must  be  stopped  until  it  has  passed 
off,  and  then  continued  more  slowly. 

Rectal  enemata  of  saline  solution  may  be  made  use  of 
instead  of  transfusion,  but  are  not  so  effectual.     In  cases 


92     The  After-Treatment  of  Operations 

of  very  severe  shock  where  the  circulation  has  ahnost 
failed,  the  fluid  is  not  absorbed  fast  enough  to  be  of  use, 
as  there  is  not  enough  circulation  to  carry  it  into  the 
great  vessels.  It  is,  however,  a  very  useful  method  when 
the  degree  of  shock  is  not  very  severe,  and  we  want  to 
prevent  it  from  increasing. 

The  water  used  for  the  injection  should  be  at  a  tempera- 
ture of  about  110°  F.  As  much  water  as  possible  should 
be  allowed  to  flow  into  the  bowel — as  a  rule  not  more  than 
I  pint  at  a  time  can  be  retained  ;  but  this  depends  to  a 
large  extent  on  the  care  with  which  it  is  injected.  By 
allowing  it  to  flow  in  quite  slowly  while  the  buttocks  are 
well  raised  on  a  bolster  it  is  often  possible  to  get  a  couple 
of  pints  retained  without  any  discomfort ;  at  least  twenty 
minutes  should  be  occupied  in  introducing  this  quantity. 
The  best  apparatus  for  injecting  the  water  is  a  No.  8 
soft  rubber  catheter,  with  a  glass  funnel  attached  to  the 
free  end  ;  the  eye  end  of  the  catheter  should  be  passed 
well  up  into  the  bowel,  and  then  the  fluid  should  be 
poured  slowly  into  the  funnel. 

Another  method  of  performing  infusion  is  by  the  sub- 
cutaneous injection  of  normal  salt  solution.  The  injection 
is  usually  made  into  the  subcutaneous  cellular  tissue  of 
the  breast.  This  method  has,  however,  no  advantages 
over  the  intravenous  or  rectal  methods,  and  on  the  other 
hand,  it  has  many  disadvantages. 

The  Use  of  Drugs, — There  are  certain  drugs  which 
have  the  property  of  causing  contraction  of  the  vessels  in 
the  peripheral  circulation,  and  of  so  raising  the  general 
blood-pressure  independently  of  the  action  of  the  vaso- 
motor centres.  It  is  obvious  that  such  drugs  are  of  the 
greatest  value  in  treating  a  condition  such  as  shock,  in 
which  it  is  necessary  to  maintain  the  circulation  until 
such  time  as  the  brain-centres  have  recovered.      There 


Surgical  Shock  93 

are  several  drugs  which  have  this  property,  but  only  three 
need  be  mentioned  here — namely,  extract  of  the  infundi- 
bular portion  of  the  pituitary  gland  (usually  called 
pituitary  extract),  adrenalin,  and  nicotine.  All  these  drugs, 
if  administered  intravenously,  will  raise  the  blood-pressure 
to,  or  above,  the  normal  level  in  the  complete  absence  of 
the  central  nervous  system.  Nicotine,  however,  owing  to 
its  poisonous  properties,  is  not  a  suitable  drug  for  clinical 
administration.  The  most  powerful  drug  of  the  three  is 
adrenalin,  which,  if  administered  in  small  doses  together 
with  saline  infusion  intravenously,  will  raise  the  blood- 
pressure  under  any  condition  of  shock.  Unfortunately, 
in  practice  this  drug  is  not  very  suitable,  owing  to  the 
fact  that  it  is  rapidly  oxidized  in  the  tissues,  and  its 
effects  are  therefore  only  transitory,  and  frequent  admin- 
istration is  required.  Moreover,  it  has  to  be  given 
intravenously,  owing  to  the  fact  that  subcutaneous  injec- 
tions have  no  effect  upon  the  bloodvessels.  Pituitary 
extract,  however,  is  a  very  valuable  drug  for  clinical  use 
in  the  treatment  of  shock.  Dr.  Symes  and  the  author 
were  able  to  prove  by  experimental  work  some  five  years 
ago  that  pituitary  extract  would  raise  the  blood-pressure 
under  any  condition  of  shock,  and  would  maintain  it  at 
or  about  the  normal  level  for  a  considerable  time  without 
readministration,  and,  moreover,  that  it  could  be  adminis- 
tered subcutaneously  provided  there  was  sufficient 
circulation  to  carry  it  into  the  general  circulation. 

It  is  obviously  useless  to  administer  pituitary  extract 
or  any  other  drug  hypodermically  to  a  patient  suffering 
severely  from  shock.  The  circulation  of  the  blood  beneath 
the  skin  has  practically  ceased  in  such  circumstances,  and 
drugs  so  administered  have  no  chance  of  reaching  the 
general  circulation.  It  is  therefore  necessary  to  inject  the 
drug  into  one  of  the  larger  veins,  such  as  the  median  basilicj 


94     The  After-Treatment  of  Operations 

or  to  administer  it  in  association  with  an  intravenous 
infusion  of  saline  solution  if  the  blood-pressure  has  already 
reached  a  very  low  level.  The  alternative  practice  in 
such  circumstances  is  first  of  all  to  infuse  the  patient 
intravenously,  and,  after  a  pint  of  fluid  has  been  run  in, 
to  inject  i  c.c.  of  pituitary  extract  into  the  india-rubher 
tube  passing  from  the  reservoir  to  the  veins,  thus  insuring 
that  the  drug  is  carried  well  into  the  circulation.  This 
drug  may  be  readministered  after  four  or  five  hours 
subcutaneously,  if  the  pressure  has  not  dropped  back  to  a 
very  low  level. 

Pituitary  extract  has  now  been  used  for  a  number  of 
years,  and  it  has  been  found  the  most  effective  method  of 
treating  shock.  It  can  now  be  obtained  in  fairly  stan- 
dardized solutions  from  the  leading  chemical  manufacturers. 
One  peculiarity  about  pituitary  extract  is  that  second  and 
third  injections  have  far  less  effect  than  the  first  one. 
The  exact  reason  for  this  has  never  been  explained,  but 
experimentally  it  is  very  marked. 

It  must  always  be  remembered  that  if  a  patient  is 
rallying  from  a  condition  of  shock  our  best  method  of 
preventing  a  relapse  is  by  keeping  him  absolutely  quiet, 
by  administering  nourishment  in  suitable  quantities  either 
by  the  mouth  or  rectum,  by  assisting  the  respiration  with 
oxygen,  and,  above  all,  by  protecting  the  central  nervous 
system  with  narcotics,  such  as  morphia  or  heroin,  at 
suitable  intervals. 

Artificial  Respiration. — This  has  often  a  remarkable 
effect  on  patients  suffering  from  shock.  It  does  good  by 
drawing  blood  into  the  chest  to  supply  the  heart,  and  by 
increasing  the  oxygenation  of  the  blood.  It  may  be  done 
gently  in  severe  cases  of  shock,  and  may  with  advantage 
be  combined  with  the  administration  of  oxygen. 

When  the  patient  remains  in  a  condition  of  shock  for 


Surgical  Shock  95 

many  hours,  it  becomes  most  important  to  administer 
nourishment  in  some  form,  as  the  condition  is  one  that 
gives  rise  to  a  great  deal  of  tissue  change,  and  the 
patient  has  probably  been  without  food  for  some  time 
previous  to  the  operation.  Some  easily  digested  form  of 
food  must  therefore  be  administered  in  the  hope  that 
some  of  it  may  be  assimilated  and  help  to  keep  up  the 
vitality  of  the  patient.  Nutrient  enemata  of  albumin  or 
peptonized  milk  should  be  given  every  one  or  two  hours, 
or  appropriate  food  may  be  given  by  the  mouth  if  the 
patient  can  swallow. 

In  conclusion,  it  must  be  borne  in  mind  that  the  condi- 
tion called  shock  which  follows  severe  operations  and 
injuries  is,  in  a  large  measure,  a  mechanical  one,  in 
which  the  circulation  is  the  main  factor  at  fault,  and  that 
therefore  it  is  a  condition  which  it  is  possible  to  treat 
successfully  in  many  cases,  since  by  appropriate  means 
the  mechanical  disadvantages  under  which  the  circulation 
is  labouring  can  be  overcome.  One  of  the  chief  factors 
in  maintaining  shock  is  the  exhaustion  of  the  nerve 
centres  in  the  cord  and  medulla,  and  although  we  cannot 
directly  influence  these,  in  most  cases  their  recovery  is 
only  a  matter  of  time,  if  meanwhile  we  can  succeed  in 
maintaining  the  circulation.  Our  efforts,  therefore,  must 
be  exerted  in  maintaining  the  circulation  in  as  efficient 
a  condition  as  possible  until  such  time  as  the  exhaustion 
of  the  nerve  centres  has  passed  off. 

We  must  not  expect  this  to  take  place  suddenly  or 
quickly  in  bad  cases,  and  considerable  patience  and  per- 
severance will  be  called  for.  The  most  difficult  cases  to 
deal  with  successfully  are  those  where  a  profound  condi- 
tion of  sepsis  or  toxaemia  is  present  in  addition  to  the 
shock  ;  it  is  often  extremely  difficult  or  impossible  to 
distinguish  the  one  condition  from  the  other,  and  patients 


96     The  After-Treatment  of  Operations 

under  such  circumstances  often  react  extremely  badly,  or 
not  at  all,  to  treatment,  and  when  they  do  react,  relapse 
again  almost  at  once. 

The  best  results  will  always  be  obtained  by  preventing 
shock  rather  than  by  treating  it. 


REFERENCES. 


'  Surgical  Shock  '  :  G.  W.  Crile,  New  York, 

'  Problems  relating  to  Surgical  Operations  '  :  Same  author. 

'  Blood-Pressure  in  Surgery  '  :  Same  author. 

'  Shock  in  Abdominal  Operations  '  :  George  Hawkins-Ambler. 

'The  Physiology  and  Treatment  of  Surgical  Shock  and  Collapse' : 

Lockhart  Mummery,  Lancet,  vol.  i.  1905,  pp.  696,  776,  846. 
'  Shock  and  Collapse  '  :  Clifford  Allbutt's  '  System  of  Medicine.' 
'  GyuEecological  Operations  '  :  Dr.  Kelly,  Baltimore. 
'The  Specific  Gravity  of  the  Blood  in  Shock  ':  Proceedings  of  thi 

Physiological  Society,  July  20,  1907. 
'  Some  Points  on  the  Experimental  Production  and  Control  of  the 

Vascular  Atony  of  Surgical  Shock  '  :   Lockhart  Mummery  and 

W,  Lrgge  Symes.    British  Medical  Journal,  September  19,  1908. 
'  Anoci-Association  ' :  G.  W.  Crile  and  W.  E.  Lower. 


CHAPTER  VI 

POST-ANESTHETIC  COMPLICATIONS 

Owing  to  the  great  improvements  in  the  methods  of 
administering  anaesthetics  which  have  taken  place  re- 
cently, the  after-effects  are  now  less  important  than 
formerly,  and  we  do  not  so  often  find  the  results  of  the 
anaesthetic  complicating  the  after-treatment  of  an  opera- 
tion case.  It  is  especially  in  the  old  and  weakly  subjects 
that  these  after-effects  are  most  likely  to  cause  trouble. 
The  after-effects  are  much  diminished  if  the  patient  has 
been  properly  prepared  for  the  anaesthetic  beforehand. 
In  some  cases,  however,  and  especially  in  emergency 
operations,  time  will  not  permit  of  the  patient  bemg 
properly  prepared  for  an  anaesthetic,  and  it  is  in  these 
cases  that  we  most  often  see  post-anaesthetic  complica- 
tions. Most  of  the  after-effects  result  more  in  dis- 
comfort to  the  patient  than  in  any  actual  danger; 
occasionally,  however,  the  results  of  the  anaesthetic, 
either  alone  or  by  complicating  some  condition  caused 
by  the  operation,  may  .give  rise  to  symptoms  of  the 
gravest  import.  The  nature  of  the  anaesthetic  used  and 
the  method  of  administration  are  of  considerable  impor- 
tance. Ether  is  undoubtedly  more  liable  to  cause 
unpleasant  after-results  than  chloroform,  but  its  other 
advantages  sufficiently   outweigh    these   to   render   it  a 

97  1 


9 8     The  After-Treatment  of  Operations 

preferable  anaesthetic  in  the  majority  of  cases.  The 
liability  to,  and  the  severity  of,  post-anaesthetic  com- 
plications are  proportionate,  to  a  large  extent,  to  the 
length  of  the  administration. 


Vomiting". 

A  certain  amount  of  vomiting  may  be  said  to  be  the 
rule  after  ether  ;  the  vomited  material  is  usually  little 
else  than  mucus,  and  vomiting  generally  passes  off  before 
the  patient  regains  consciousness.  Occasionally,  how- 
ever, it  is  more  severe,  and  may  continue  for  many  hours 
or  even  days.  When  this  is  the  case  it  is  very  distress- 
ing to  the  patient,  and  may  be  dangerous,  by  lowering 
his  strength  and  preventing  the  proper  assimilation  of 
nourishment. 

Vomiting  is  more  liable  to  occur  if  the  patient  is  jolted 
or  moved  carelessly  soon  after  the  anaesthetic ;  care 
should  therefore  be  exercised  in  moving  the  patient  back 
to  bed,  both  to  avoid  jolting  and  to  keep  him  as  flat  as 
possible.  The  cause  of  the  vomiting  has  been  attributed 
to  the  presence  of  ether  in  the  stomach.  Hess  of  New 
York,  who  has  investigated  this  subject,  comes  to  the 
conclusion  that  the  drug  is  excreted  by  the  gastric 
mucous  membrane,  and  as  it  is  usual  for  the  stomach  to 
be  empty  during  an  operation,  it  remains  there  in  a  con- 
centrated form  mixed  with  mucus ;  no  doubt  also  a 
considerable  quantity  of  ether  finds  its  way  into  the 
stomach  with  the  saliva  which  is  swallowed.  Hess 
considers  that  the  bad  cases  of  post-anaesthetic  vomiting 
are  due  to  a  gastritis  set  up  by  the  ether  present  in  the 
stomach,  and  suggests  that  the  best  way  of  preventing 
this  is  by  diluting  the  stomach  contents.  He  advises 
that  the  patient  should  be  given  a  draught  of  water  before 


Post-Angssthetic  Complications         99 

the  commencement  of  the  anaesthetic,  so  that  any  ether 
that  may  find  its  way  into  the  stomach  will  be  rapidly 
diluted.  Whether  the  vomiting  is  due  to  any  local  con- 
dition of  the  stomach  or  is  of  central  nervous  origin  is 
still  somewhat  doubtful ;  that,  at  any  rate,  the  vomiting 
is  not  entirely  due  to  local  causes  seems  probable,  as 
vomiting  follows  the  anaesthesia  produced  by  rectal 
etherization.  And,  again,  some  of  the  worst  cases  of 
vomiting  occur  after  chloroform.  That  ether  does  get 
into  the  stomach  during  the  administration  of  the  anaes- 
thetic there  can  be  no  doubt,  and  draughts  of  water  after 
the  administration,  whether  retained  or  not,  will  assist  in 
either  diluting  or  washing  it  away. 

Although  vomiting  is  more  common  after  ether  than 
after  chloroform,  the  worst  cases  of  vomiting  are  seen 
after  the  latter  drug.  The  presence  of  blood  in  the 
stomach  (which  has  been  swallowed  during  the  anaes- 
thesia) is  a  common  cause  of  subsequent  vomiting.  In 
children,  vomiting  after  ether  is  very  much  less  common 
than  with  adults,  in  spite  of  the  fact  that,  as  a  rule, 
children  are  sick  from  very  slight  causes ;  and  it  seems 
that  old  people  are  also  less  liable  to  post-anaesthetic 
vomiting. 

The  position  of  the  patient  after  an  anaesthetic  is  of 
some  importance  in  preventing  sickness.  The  patient 
should  be  turned  on  to  the  right  side  if  possible,  so  as  to 
allow  any  fluid  in  the  stomach  to  find  its  way  easily  into 
the  duodenum.  In  cases  of  very  intractable  vomiting, 
propping  the  patient  up  into  a  sitting  or  half-sitting 
position  will  often  be  efficacious  in  stopping  the  sickness. 
When  the  vomiting  consists  in  simple  regurgitation  of 
fluids  directly  they  are  swallowed,  this  is  all  that  is 
usually  necessary  to  stop  it  and  enable  the  patient  tq 
retain  nourishment. 


loo     The  After-Treatment  of  Operations 

Another  point  of  great  importance  with  regard  to  the 
posture  after  an  anaesthetic  may  be  referred  to  here — that 
is,  that  after  the  patient  has  been  put  back  to  bed,  and 
before  he  has  regained  consciousness,  the  head  must  be 
kept  well  to  one  side,  as  if  he  be  allowed  to  lie  on  the 
back  with  his  head  in  the  midline,  should  any  sickness 
occur  there  is  a  great  danger  of  the  vomited  material 
becoming  sucked  into  the  air-passages  and  obstructing 
respiration.  This  may  occur  even  though  a  nurse  is 
watching  the  patient,  and  several  deaths  have  been  re- 
corded from  this  cause  after  the  administration  of  ether. 

When  from  the  nature  of  the  operation  it  is  particu- 
larly advisable  that  the  patient  should  not  vomit  after 
the  operation  is  finished,  or  when  it  is  known  that  the 
particular  patient  is  liable  to  exceptionally  severe  vomit- 
ing after  anaesthesia,  an  excellent  plan  is  to  wash  out  the 
stomach  with  warm  water  before  sending  the  patient 
back  to  bed  ;  this  is  often  effectual  in  completely  pre- 
venting vomiting. 

As  soon  as  the  patient  is  conscious  after  the  anaes- 
thetic, if  vomiting  does  not  cease  he  may  be  given 
some  quite  hot  water  to  drink  (about  |  pint  may  be 
allowed)  ;  this  will  sometimes  have  the  effect  of  making 
the  patient  sick,  but  will  do  no  harm,  as  it  washes  out 
the  stomach  and  gets  rid  of  the  ether. 

Another  plan  is  to  give  15  to  20  grains  of  bicarbonate 
of  potash  in  |  pint  of  hot  water ;  or  3  minims  of  tinc- 
ture of  iodine  dissolved  in  ^  pint  of  cold  water  is  some 
times  very  effectual.  Another  way  of  giving  iodine  is 
I  minim  of  iodine  in  i  drachm  of  water  every  two  hours. 
Strong  hot  coffee  may  be  tried,  or  champagne  is  some- 
times useful. 

There  are  several  drugs  which  enjoy  a  reputation  for 
preventing  vomiting  after  anaesthesia ;  thus  hydrocyanic 


Post-Anaesthetic  Complications       loi 

acid  in  small  repeated  doses  is  said  to  be  of  value. 
Morphia  is  certainly  sometimes  of  use,  and  may  be  given 
either  hypodermically  or  by  the  mouth.  Sir  F.  Hewitt 
says  that  when  there  is  a  neurotic  element  in  the  vomiting, 
bromide  of  potassium  may  be  given  as  an  enema  (20  grains 
in  2  ounces  of  water)  with  good  results.  Sometimes 
10  grains  of  bromide  placed  on  the  back  of  the  tongue  is 
effectual. 

Counter-irritants  to  the  region  of  the  stomach  are  some- 
times effectual.  The  best  of  these  is  a  flannel  rung  out  of 
boiling  water  and  applied  to  the  epigastrium  ;  it  must  be 
applied  as  hot  as  possible  and  changed  as  soon  as  it  has 
become  cool.     Blisters  have  also  been  used  with  success. 

Strong  essence  of  peppermint  is  sometimes  very 
effectual ;  it  is  best  given  as  5  or  10  drops  on  a  lump 
of  sugar,  the  latter  being  sucked  slowly,  or  it  may  be 
given  with  a  little  water  :  it  probably  acts  in  the  same 
way  as  a  counter-irritant.  In  cases  of  very  severe  and 
intractable  sickness  the  stomach  should  be  washed  out 
with  warm  water  by  means  of  a  soft  rubber  tube,  until 
the  water  comes  back  quite  clean ;  this  removes  any 
decomposing  or  irritating  material  that  may  be  present, 
and  it  is  the  most  effectual  method  we  possess  of  stopping 
vomiting.  The  repeated  inhalation  of  oxygen  has  some- 
times proved  effectual  in  controlling  vomiting  in  bad 
cases.  Patients  who  have  suffered  from  severe  vomiting 
often  complain  of  pain  round  the  lower  part  of  the  chest, 
especially  on  deep  inspiration,  for  a  day  or  two  after- 
wards ;  this  is  due  to  the  muscles  having  been  strained 
during  the  violent  retching.  This  pain  often  gives  rise 
to  a  great  deal  of  discomfort,  and  may  even  give  rise  to  a 
suspicion  of  pleurisy.  It  should  be  relieved  by  rubbing 
the  skin  over  the  painful  muscles  with  linamentum 
saponis  or  by  gentle  massage. 


io2     The  After-Treatment  of  Operations 
Lungr  Complications. 

The  liability  to  lung  complications  after  anaesthetics  is 
probably  greater  than  is  usually  supposed.  These  com- 
plications are  most  commonly  seen  after  ether,  and  but 
rarely  after  chloroform.  The  most  common  of  these 
complications  is  bronchitis,  which  may  go  on  to  broncho- 
pneumonia in  bad  cases.  The  so-called  ether  pneumonia, 
which  is  of  the  lobar  type,  seems  to  be  much  more  rare 
than  its  name  would  imply. 

The  term  '  ether  pneumonia,'  though  commonly  used, 
is  a  bad  one,  and  '  post-operative  pneumonia  '  would  be 
better.  That  ether  is  not  responsible  for  all  the  cases 
of  pneunomia  which  occur  soon  after  an  operation  is 
shown  by  the  fact  that  pneumonia  also  occurs  after 
chloroform  and  infiltration  an?Esthesia.  There  is  little 
doubt  that  many  of  the  cases  quoted  as  '  ether  pneumonia  ' 
are  due  to  infarction  of  the  lung.  This  is  also  borne  out 
by  the  fact  that  pneumonia  more  frequently  occurs  after 
abdominal  and  pelvic  operations,  and  it  will  be  seen  by 
reference  to  the  chapter  on  Thrombosis  that  these  are 
the  operations  after  which  infarction  is  most  liable  to 
occur. 

Crouch  and  Corner,  who  investigated  this  subject 
recently  at  St.  Thomas's  Hospital,  found  in  2,400 
administrations  of  ether,  ten  cases  of  subsequent  lung 
complications  which  were  directly  attributable  to  the 
anaesthetic.  Of  these  ten  cases,  three  were  broncho- 
pneumonia (one  of  whom  died),  one  developed  pleurisy, 
and  the  remainder  bronchitis  of  varying  degrees  of 
severity.  It  may  be  mentioned  that  in  this  series  of 
cases  the  anaesthetics  were  given,  for  the  most  part,  by 
inexperienced  anaesthetists.  The  liability  to  these  com- 
plications appears  to  be  greater  after  prolonged  anaesthesia, 


Post-Anaesthetic  Complications      103 

and  especially  when  the  patient  is  subjected  to  changes 
of  temperature  or  draughts  soon  after  the  administra- 
tion, as  is  the  case  when  he  has  to  be  conveyed  along 
passages,  etc.,  on  the  way  from  the  operating-table  to 
the  bed.  It  is,  therefore,  commoner  in  hospital  than  in 
private  practice.  To  prevent  these  complications  great 
care  should  be  taken  not  to  let  the  patient  be  subjected 
to  any  draught  or  sudden  change  of  temperature  after  an 
anaesthetic,  and  if  it  is  necessary  to  move  a  patient  some 
distance  from  the  operating-room,  the  head  and  mouth 
should  be  covered  over  with  a  thin  blanket.  The  treat- 
ment is,  of  course,  that  which  is  appropriate  for  the  lung 
condition  present.  Many  cases  of  '  ether  pneumonia'  are 
really  lobar  collapse  m  connection  with  inhibited  action 
of  the  diaphragm  during  and  after  abdominal  operations. 

Other  Complications. 

Among  other  complications  that  may  be  seen  are  the 
following  : 

Renal  Troubles. — Some  observers  state  that  albu- 
minuria for  a  day  or  two  is  very  common,  and  is  more 
often  seen  after  chloroform  than  after  ether.  Two  cases 
have  recently  been  reported  in  which  uraemic  coma 
followed  an  anaesthetic.  Disease  of  the  kidneys  was  found 
to  be  present  in  both  cases  at  the  post-mortem.  Such 
cases  show  the  importance  of  examining  the  urine  before 
giving  an  anaesthetic. 

Jaundice  has  been  recorded  as  occurring  after  chloro- 
form. 

Insanity. — Several  cases  of  this  have  been  recorded. 
It  is  specially  liable  to  occur  in  patients  the  subjects  of 
recurring  attacks  of  insanity,  the  anaesthetic  acting  as  the 
exciting  cause  in  bringing  on  another  attack. 

Diabetic  Coma  has  been  known  to  be  brought  on  by 
the  administration  of  an  anaesthetic.     Of  course,  this  is 


104    The  After-Treatment  of  Operations 

best  prevented  by  carefully  dieting  the  patient  before  the 
operation. 

Paralysis. — Dr.  Blumfeld  mentions  three  varieties  of 
paralysis  that  may  follow  anaesthesia :  (i)  Those  of 
peripheral  origin.  These  are  due  to  the  patient,  while 
his  volition  is  in  abeyance,  being  allowed  to  remain  for 
some  time  in  a  strained  position,  which  has  resulted  in 
some  nerve  or  nerves  being  pressed  upon.  Deltoid  and 
ulnar  paralysis  are  examples.  (2)  Those  of  central  origin. 
These  are  really  apoplectic  fits,  resulting  from  the  con- 
gestion due  to  the  anaesthetic.     (3)  Indeterminate. 

Persistent  Hiccough, — This  may  occur  and  prove 
very  difficult  to  stop.  Tongue  traction  has  sometimes 
been  successful. 

H^MATEMESis. — -This  complication  is  very  rare,  but  is 
sometimes  seen  after  operations,  and  it  is  doubtful  how 
much  of  it  is  due  to  the  anaesthetic  and  how  much  to  the 
operation  itself.  It  seems  to  be  commoner  after  operations 
on  the  intestinal  tract  than  after  operations  on  other  parts 
of  the  body.  A  case  is  reported  in  the  Lancet,  August  22, 
1902,  where  hsematemesis  occurred  four  days  after  the 
operation,  and  Mr.  Mayo  Robson  cites  several  cases  of 
this  complication,  some  of  which  were  fatal. 

HEMOPTYSIS. — This  also  is  a  rare  complication,  but  is 
occasionally  seen.  Of  course,  as  a  rule  it  is  seen  in 
tubercular  patients  who  have  cavities  in  the  lungs,  and 
the  congestion  resulting  from  the  anaesthetic  acts  as  the 
exciting  cause.  Sometimes,  however,  no  history  of  any 
previous  lung  trouble  is  obtainable,  and  on  examination 
of  the  chest  it  is  not  posible  to  discover  any  signs  of 
mischief.  It  is,  as  one  would  naturally  suppose,  most 
commonly  seen  after  ether. 

Delayed  Chloroform  Poisoning  is  a  condition  in 
which   the   patient,  usually  a   child,  having  apparently 


Post-AnsBSthetic  Complications  105 

recovered  from  the  effects  of  the  anaesthetic,  begins  to 
vomit  repeatedly.  The  onset  is  usually  twelve  to  thirty- 
six  hours  after  operation ;  the  vomiting  continues,  acetone 
appears  in  the  urine,  the  temperature  rises,  and  delirium, 
restlessness,  and  coma  supervene,  terminating  in  death. 
Milder  forms  of  this  complication,  from  which  patients 
have  recovered,  have  also  been  described.  The  most 
hopeful  form  of  treatment  is  stated  to  be  repeated  wash- 
ing out  of  the  stomach  with  solutions  of  bicarbonate  of 
soda  (5i.  to  the  pint),  a  small  quantity  of  the  solution 
being  left  behind  in  the  stomach.  Glucose  should  also 
be  given  per  rectum. 

Diet. 
As  a  rule,  no  food  should  be  given  by  the  mouth  for 
from  four  to  six  hours  after  the  anaesthetic,  as  it  will 
probably  only  cause  vomiting.  The  first  food  that  is 
given  should  be  something  that  is  easily  assimilated,  but 
need  not  necessarily  be  fluid.  Solids  or  semi-solids  are 
often  more  readily  retained,  and  are  more  satisfying  to 
the  patient.  A  cup  of  tea  with  some  soft  bread-and- 
butter  and  a  lightly-boiled  eg^g  may  be  given.  Anything 
in  the  way  of  a  large  meal  should  not  be  allowed,  as  it 
will  almost  certainly  cause  sickness.  When  the  adminis- 
tration has  been  a  long  one,  of  course  the  interval  that 
must  be  allowed  to  elapse  before  food  is  given  should  be 
longer.  On  the  day  following  the  operation  the  patient 
may  be  allowed  to  go  back  to  his  ordinary  diet  if  there  is 
no  sickness  and  it  is  not  otherwise  contra-indicated  by 
the  nature  of  the  operation. 


REFERENCES. 


Anaesthetics  '  :  Sir  F.  Hewitt. 

Vomiting    after    Anaesthetics '  :    Dr.    Biumfeld,    Clinical   Journal, 
August,  1901. 


CHAPTER  VII 

THROMBOSIS  FOLLOWING  OPERATIONS 

This  is,  fortunately,  a  rare  complication.  It  may  result 
from  two  conditions  :  (i)  After  a  prolonged  or  severe 
operation  upon  an  anaemic  subject ;  (2)  as  the  result  of 
sepsis  in  the  wound.  The  thrombosis  differs  considerably, 
according  to  which  of  these  conditions  has  caused  it, 
both  as  to  its  type  and  its  liability  to  give  rise  to  infarc- 
tion. In  the  first  case,  the  thrombus  is  due  to  stagna- 
tion of  the  blood  and  infarction  if  it  occurs,  will  do  so 
during  the  period  of  formation  of  the  clot,  and  there  is 
very  little  tendency  for  it  to  do  so  later.  In  the  second 
case,  the  thrombus  is  a  septic  one,  and  the  chief  period  of 
danger  is  during  the  softening  of  the  clot ;  moreover,  in 
this  case,  if  infarction  occurs  abscess  will  probably  form 
at  the  site  of  the  infarct,  and  a  condition  similar  to 
pyaemia  will  be  set  up.  It  is  well  to  bear  these  facts  in 
mind  as  it  is  of  the  utmost  importance  that  the  patient 
should  be  kept  absolutely  quiet  during  the  dangerous 
period.  There  seems  to  be  an  exceptional  liability  to 
bed-sores  in  some  of  these  cases,  and  if  the  case  is  a  septic 
one  necessitating  prolonged  immobility,  it  is  best  to  turn 
the  patient  on  to  his  face,  lifting  him  on  a  sheet  so  as 
to  disturb  him  as  little  as  possible.  The  liability  to  the 
formation  of  bed-sore  is  much  less  in  this  position,  as  has 
already  been  pointed  out. 

106 


Thrombosis  following  Operations    107 

Thrombosis  most  commonly  occurs  about  a  week  or 
ten  days  after  the  operation,  though  it  may  take  place 
very  much  earlier  than  this,  and,  as  in  the  second  of  the 
appended  cases,  it  may  occur  as  late  as  three  weeks  after- 
wards. In  a  resume  of  forty-eight  cases  of  crural 
thrombosis  following  surgical  operations  collected  by 
Shenck,  and  reported  in  the  New  York  Medical  Journal, 
September  6,  1902,  it  was  found  that  out  of  a  total 
of  7,130  gynaecological  operations  there  were  forty- 
eight  cases  of  thrombosis  of  the  veins  of  the  lower 
extremity. 

In  the  more  recent  statistics  from  the  Mayo  clinic 
for  the  year  1913  (Beckman,  'Complications  following 
Surgical  Operations,'  Journ.  Surg.,  GyncBcoL,  and  Ohstetrics, 
May,  1914)  there  were  fourteen  cases  out  of  a  total  of 
6^825  cases.  These  figures  show  a  very  marked  improve- 
ment, and  are  what  one  would  expect  as  the  result  of  the 
improved  technique  and  greater  attention  to  after-treat- 
ment that  have  been  the  chief  features  of  surgical  advance 
in  the  last  ten  years.  The  fourteen  cases  in  these  last 
statistics  occurred  in  twelve  different  types  of  operations, 
although  all  were  abdominal  operations.  The  conclusion 
arrived  at  from  these  figures  is  that  there  is  no  special 
liability  for  thrombosis  to  occur  in  septic  cases  as  opposed 
to  clean  ones. 

Shenck  also  points  out  that  this  complication  is  much 
more  common  after  operations  on  the  pelvis,  than  after 
operations  on  any  other  part  of  the  body,  and  that  injury 
to  the  large  venous  trunks  by  the  too  forcible  use  of 
retractors  is  a  possible  cause  in  some  cases.  Ligature  of 
a  vein  close  to  the  point  at  which  it  enters  the  main 
venous  trunk  may  cause  thrombosis  in  that  trunk  by 
extension  of  the  clot,  and  this  was  thought  to  be  the 
cause  in  some  of  Shenck's  cases.      The  most  common 


io8    The  After-Treatment  of  Operations 

date  for  the  onset  of  this  compHcation  was  found  in  this 
series  of  cases  to  be  between  the  twelfth  and  sixteenth 
days  after  the  operation.  It  was  found  that  the  anaemia 
and  cachexia  accompanying  malignant  disease  was  a 
factor  in  many  of  the  cases  where  thrombosis  followed 
operation  for  the  relief  of  this  condition.  An  infective 
origin  for  the  thrombosis  was  also  traceable  in  many  of 
the  cases. 

In  an  investigation  carried  out  by  Wright  and  Knapp 
into  the  cause  of  post-typhoid  thrombosis,  it  was  shown 
that  there  was  a  decrease  in  the  coagulation  time  of 
the  blood  of  typhoid  patients  during  the  later  stages  of 
that  disease  (i.e.,  that  the  blood  coagulates  more  rapidly 
than  normal),  and  that  this  increased  coagulability  is 
accompanied  by  an  increase  in  the  amount  of  calcium 
salts  present  in  the  blood.  This  increase  in  the  calcium 
salts  is  attributed  to  the  fact  that  typhoid  patients  are  fed 
almost  exclusively  on  a  milk  diet,  which  contains  a  high 
percentage  of  these  salts.  If  this  view  is  correct,  and  it 
seems  a  reasonable  one,  and  is  well  backed  by  experi- 
mental evidence,  the  thrombosis  following  typhoid  is  in 
part  due  to  a  milk  diet.  And  it  is  possible  that  some  of 
the  cases  of  thrombosis  that  follow  operations  are  due  to 
the  same  cause.  Wright  and  Knapp  suggest  the  use  of 
citric  acid  to  precipitate  the  calcium  salts  as  a  prophy- 
lactic agent. 

It  would  seem  that  operations  in  the  neighbourhood 
of  the  pelvis  are  those  most  liable  to  be  followed  by 
thrombosis,  and  that  this  is  attributable  to  direct  injury 
or  infection  of  the  main  venous  channels  or  the  ligature 
of  their  immediate^  branches.  Anaemic  or  cachetic  con- 
ditions undoubtedly  predispose  to  the  condition. 

The  onset  of  thrombosis  is  usually  accompanied  by 
pain  in  the  part  or  by  itching.     This  pain  is  generally  of 


Thrombosis  following  Operations      109 

a  dull,  aching  character.  On  examining  the  part  there 
is  found  to  be  tenderness  over  the  site  of  the  vein,  or  the 
thrombosed  vein,  if  superficial,  may  sometimes  be  felt 
like  a  lead  pencil  beneath  the  skin.  The  greatest  care 
must,  however,  be  taken  in  examining  a  patient  in  whom 
thrombosis  is  suspected,  as  otherwise  there  is  great 
danger  of  dislodging  the  clot.  The  treatment  should 
consist  in  wrapping  the  affected  parts  in  cotton-wool  and 
elevating  the  limb.  Absolute  rest  in  bed  for  at  least  five 
weeks  is  usually  necessary,  and  this  time  may  have  to  be 
considerably  extended.  Splints  should  not  be  used,  but 
the  limb,  if  necessary,  may  be  steadied  by  sand-bags. 

Great  care  must  be  exercised  in  the  nursing,  especially 
during  the  period  when  the  clot  is  extending,  and  the 
patient  must  be  moved  as  little  as  possible  and  very  care- 
fully, otherwise  there  is  great  danger  of  a  portion  of  the 
clot  becoming  detached  and  giving  rise  to  an  infarct  in 
the  lung  ;  the  patient  should  also  be  warned  as  to  the 
danger  of  moving.  For  the  same  reason  anything  in  the 
nature  of  a  purge  must  not  be  given,  and  if  there  is  any 
difficulty  in  getting  the  patient's  bowels  to  act,  enemas 
should  be  used. 

Roughly  speaking,  it  may  be  said  that  in  the  non-septic 
cases  most  of  the  danger  of  infarction  is  over  in  a  fort- 
night from  the  commencement  of  the  thrombosis.  In 
the  septic  cases  the  time  is  longer,  being  roughly  five  or 
six  weeks.  When  there  is  marked  anaemia,  it  is  most 
important  to  treat  this  condition  by  careful  attention  to 
diet  and  the  administration  of  iron  in  some  form  or 
another. 

When  infarction  does  occur  and  is  not  immediately 
fatal,  the  patient  should  be  sat  up  and  oxygen  adminis- 
tered to  relieve  the  dyspnoea,  which  is  very  distressing  ; 
some  stimulant  is  usually  necessary,  such  as  strychnine 


1 1  o     The  After-Treatment  of  Operations 

or  brandy.  As  soon  as  the  dyspncea  has  to  some  extent 
passed  off,  which  in  most  cases  is  in  about  five  or  ten 
minutes,  the  patient  should  be  propped  up  with  pillows 
and  kept  as  quiet  as  possible.  Alkalies,  and  especially 
ammonium  carbonate,  seem  to  be  of  some  value  in  pre- 
venting further  extension  of  the  clot,  and  may  be  given 
in  large  doses  by  the  mouth.  In  thrombosis  of  septic 
origin,  if  the  position  of  the  clot  will  permit  of  it,  the 
vein  on  the  proximal  side  of  the  clot  may  be  cut  down 
and  ligatured.  When  sudden  death  has  occurred  from 
infarction  and  the  medical  attendant  is  at  hand,  it  is 
always  worth  while  to  try  and  restore  the  patient  by 
artificial  respiration,  etc.,  as  the  cause  of  death  in  most 
cases  is  quite  momentary. 

Infarction  is  usually  accompanied  by  a  rise  of  tempera- 
ture to  ioi°  or  102°  F. ;  the  temperature  falls  again  in 
twenty-four  hours,  as  a  rule,  though  it  may  remain 
slightly  elevated  for  some  days.  In  the  septic  cases 
there  is,  of  course,  the  ordinary  septic  temperature.  A 
careful  examination  of  the  chest  on  the  day  after  infarc- 
tion has  taken  place  will  sometimes  reveal  a  patch  of 
consolidated  lung  corresponding  to  the  area  cut  off  by  the 
infarct. 

Illustrative  Cases  of  Thrombosis  and  Infarction 
following  Operations. 

Case  i  (Fig.  17).  Thrombosis  following  Operation  for  Appen- 
dicitis.— A  rather  ansemic-looking  girl  was  admitted  with  s3-mptoms 
of  acute  appendicitis.  At  the  operation,  which  was  performed  on 
January  16,  a  large  abscess  containing  much  foul  pus  was  opened 
and  drained.  The  case  progressed  favourably  for  the  next  few 
days,  and  there  was  free  discharge  of  pus  from  the  wound.  On  the 
22nd  (six  days  after  the  operation)  the  patient  complained  in  the 
morning  of  some  pain  in  the  right  leg,  and  it  was  discovered  on 
examination  that  the  right  femoral  vein  and  most  of  the  veins  of  the 
calf  were  thrombosed.     At  3  p.m.  the  same  day  the  patient  had  a 


Thrombosis  following  Operations      1 1 1 

sudden  attack  of  dyspnoea,  faintness,  and  cyanosis.  She  was  very 
bad  for  some  few  minutes,  but  was  relieved  by  the  inhalation  of 
oxygen  and  an  injection  of  strychnine.  She  had  to  sit  up.  The 
respirations  were  50. 

On  the  23rd  the  patient  was  still  dyspnoeic.     Respirations  40. 

This  condition  remained  practically  unchanged  till  the  26th. 
Nothing  at  this  time  was  found  in  the  lungs.  The  condition  now 
improved,  but  on  the  night  of  the  28th  there  was  another  attack  of 
dyspnoea  (i.e. ,  another  infarct).  There  was  at  this  time  some  oedema 
of  both  legs,  and  both  the  femoral  veins  were  thrombosed.  The 
legs  were  dressed  with  lead  and  opium  lotion,  and  20  grains  of 
ammonium  carbonate  was  given  three  times  daily  by  the  mouth. 
The  wound  was  now  almost  healed,  and  the  tubes  had  been 
removed.  On  February  6  the  patient  complained  of  pain  and  stiff- 
ness of  the  right  shoulder,  and  it  was  noticed  that  the  superficial 
veins  of  the  right  side  of  the  chest  and  all  down  the  arm  were 
dilated.  All  the  veins  of  this  region  that  could  be  seen  or  felt  were 
found  to  be  thrombosed,  and  it  appeared  certain  that  the  right 
innominate  vein  was  thrombosed. 

On  the  nth  an  eczematous  rash  appeared  over  the  legs,  chin, 
and  right  hand.  There  were  no  further  infarcts,  and  the  patient 
rapidly  improved.  The  thromboses  all  cleared  up  in  the  course  of 
about  ten  days  or  a  fortnight  after  this,  and  the  patient  left  the 
hospital  quite  well  on  March  6. 

At  first  the  patient  was  fed  with  albumin  water,  but  after  the  ap- 
pearance of  the  thrombosis  a  more  nourishing  fluid  diet  was  allowed. 


V-    : 

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Fig.  17. 


and  iron  in  the  form  of  cachets  of  pil.  ferri  (5  grains)  was  given 
three  times  a  day  ;  half  a  pint  of  stout  was  also  given  daily  and 
port  wine.     For  the  pain  and  distress  when  the  infarction  took  place 


112     The  After-Treatment  of  Operations 

a  hypodermic  injection  of  morphia  was  administered.  Large  doses 
of  alkaHes,  sodium  bicarbonaie,  and  ammonium  carDonate  were 
given  throughout. 

In  what  way  alkalies  act  in  the  treatment  of  these  cases 
is  very  doubtful,  but  they  seem  to  have  a  very  beneficial 
effect. 

Case  2  (Fig.  iS).  Thrombosis  following  an  Operation  for 
Appendicitis. — This  was  the  case  of  a  man,  aged  forty-five,  who 
was  operated  on  for  acute  appendicitis,  and  had  a  large  abscess  in  the 
neighbourhood  of  the  appendix  drained.  About  twelve  days  after  the 
operation  the  patient  had  what  was  described  as  an  acute  cardiac 
attack,  accompanied  by  very  severe  dyspnoea.  (This  seems  to  have 
undoubtedly  been  an  infarct  in  the  lung.)  There  was  at  the  same 
time  cedema  of  the  right  leg,  and  the  femoral  vein  was  found  to  be 
thrombosed.  A  week  later  there  was  another  attack  of  a.  similar 
nature  to  the  first  one.     After  this  attack  some  friction  was  noticed 


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Fig.  18. 

on  listening  with  the  stethoscope  over  the  lower  part  of  the  left  side 
of  the  chest.  The  thrombosis  gradually  cleared  up,  and  the  patient 
was  able  to  go  away  to  the  country  two  months  after  the  operation. 

The  temperature  charts  of  both  these  cases  are  appended, 
and  it  will  be  noticed  that  there  is  a  rise  of  temperature 
coincident  with  the  infarction  of  the  lung. 


Case  3  (Fig.  19).  Thrombosis  following  an  Operation  for 
Hernia. — A  woman,  aged  forty-nine,  was  operated  upon  for  the 
radical  cure  of  a  hernia  on  the  right  side,  on  November  22. 

On  the  third  day  after  the  operation  there  was  a  slight  rise  in  the 
temperature.     This,  however,  dropped  again,  and  remained  normal 


Thrombosis  following  Operations      i  1 3 

till  the  28th.,  when  it  again  rose,  and  continued  high.  On  De- 
cember 2,  as  sepsis  was  suspected,  the  wound  was  dressed,  though 
the  patient  complained  of  no  pain  in  the  wound.  The  wound  was 
found  to  be  quite  healthy,  and  almost  healed.  On  this  day  pain  was 
complained  of  in  the  calf  of  the  left  leg,  and  on  examination  it  was 
found  that  the  iliac,  femoral,  and  saphena  veins  were  all  thrombosed. 
There  was  some  cystitis  present,  for  which  she  was  treated  by 
washing  out  the  bladder. 

The  same  afternoon,  while  being  moved  in  bed,  she  had  an  infarct 
in  the  lung.  There  was  sudden,  very  severe  dyspncsa;  the  pulse 
became  irregular  and  uncountable,  and  she  was  in  great  distress. 
Oxygen  and  stimulants  were  administered,  and  she  gradually 
rallied.  On  December  6  she  had  another  pulmonary  infarct,  which 
almost  proved  fatal.  On  December  27  she  had  another  pulmonary 
infarct  of  a  severe  nature,  and  another  less  severe  attack  on  the 
28th.  At  this  time  the  patient  was  very  ill  indeed,  and  vomited 
everything.     There  was  much  dyspnoea,  and  she  was  very  cyanosed. 


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The  breathing  gradually  improved  in  the  course  of  the  next  few 
days. 

On  January  8  a  large  sloughing  bed-sore  formed  over  the  sacrum, 
and  she  was  accordingly  turned  on  to  her  face  and  subsequently 


114    The   After-Treatment  of  Operations 

nursed  in  this  position.  The  bed-sore  was  very  septic,  and  con- 
tained much  gangrenous  tissue.  From  time  to  time  there  were 
rigors,  and  her  temperature  remained  high. 

On  February  3  her  temperature  went  up  very  high,  and  she 
became  extremely  ill. 

On  February  12  she  had  several  rigors,  and  developed  a  bad 
cough,  though  no  signs  could  be  discovered  in  the  chest. 

On  February  28  she  coughed  up  a  quantity  of  pus  on  two 
occasions. 

After  this  the  temperature  gradually  came  back  to  the  normal, 
and  by  April  10  the  cough  had  disappeared,  and  she  soon  afterwards 
left  the  hospital  for  the  seaside. 

This  case  was  one  of  septic  thrombosis,  though  the 
cause  of  infection  is  somewhat  doubtful.  It  may  have 
been  from  the  wound  (which,  however,  did  not  break 
down),  or  from  the  cystitis  which  was  present.  It  shows 
very  well  how  much  more  dangerous  these  cases  are  than 
those  of  simple  thrombosis,  and  how  the  danger  of  infarct 
extends  for  a  much  longer  time. 

There  can  be  little  doubt  that  the  bed-sore  and  the 
abscess  in  the  lung  were  due  to  septic  emboli.  There 
were  no  signs  of  the  lung  abscess  for  over  two  months 
from  the  time  of  the  formation  of  the  thrombus ;  this 
shows  the  great  importance  of  complete  rest  in  bed  for 
a  long  time  in  these  septic  cases.  Cases  of  pulmonary 
embolism  are  often  more  serious,  there  being  no  indica- 
tion of  anything  wrong  before  the  sudden  onset  of 
dyspnoea  and  death.  These  cases  are  veritable  tragedies, 
death  often  occurring  in  a  few  minutes  without  any 
warning,  though  the  patient  was  apparently  doing  well. 
In  most  of  these  suddenly  fatal  cases  an  autopsy  will 
reveal  the  presence  of  a  clot  in  the  right  pulmonary 
artery  and  thrombosis  of  the  femoral  or  pelvic  veins. 


Thrombosis  following  Operations      1 1 5 


REFERENCES. 

'  Crural  Thrombosis  following  Surgical  Operations ':  B.  R.  Shenck. 
New  York  Medical  Jow/nal,  September  6,  1902. 

'  Post-Typhoid  Thrombosis ' :  Drs.  Wright  and  Knapp.  Lancet, 
December  6,  1902. 

Dr.  Wright  and  Dr.  Paramore.     Lancet,  October  14,  1905. 

'  Pulmonary  Embolism  and  Thrombosis  after  Laparotomy  ' :  L.  Bid- 
well.     Practitioner,  February,  1909. 

'  Complications  following  Surgical  Operations ' :  Beckman.  Surgery, 
Gynecology,  and  Obstetrics,  May,  1914. 


CHAPTER  VIII 

POST-OPERATIVE  RASHES  AND  DRUG-POISONING 

Septic  Rashes. 

For  a  long  time  great  confusion  has  existed  in  the 
diagnosis  of  rashes  following  operations,  and  hitherto 
many  of  them  have  been  called  scarlet  fever.  Some 
text-books  describe  a  form  of  scarlet  fever  called  'surgical 
scarlatina,'  which  occurs  in  patients  with  open  wounds  ; 
it  seems  most  probable  that  this  is  really  a  septic  condi- 
tion. Though  undoubtedly  there  are  from  time  to  time 
cases  where  a  genuine  attack  of  scarlet  fever  follows  an 
operation,  careful  investigation  seems  to  show  that  these 
cases  are  rare,  and  that  most  of  the  cases  described  as 
scarlet  fever  following  injury  or  operation  are  in  reality 
septic  in  origin. 

A  septic  rash  generally  makes  its  appearance  at  the 
time  that  other  septic  manifestations  usually  appear — 
that  is  to  say,  from  one  to  four  days  after  the  operation 
— though  the  time  after  the  operation  at  which  the  rash 
appears  is  often  slightly  shorter  than  in  the  case  of 
ordinary  sepsis  in  the  wound,  as  the  nature  of  the 
infection  is  more  acute.  The  appearance  of  the  rash  is 
generally  accompanied  by  a  marked  rise  in  temperature 
to  102°  to  103°  F.,  and  is  followed  by  other  constitutional 

116 


Post-Operative  Rashes  117 

symptoms,  such  as  malaise,  rapid  pulse,  restlessness,  etc. 
The  rash  itself  is  usually  a  scarlet  erythema,  which  much 
resembles  the  rash  of  scarlet  fever.  It  usually  appears 
quite  suddenly  in  the  course  of  a  few  hours.  Often  the 
rash  is  an  almost  uniform  injection  of  the  skin,  at  other 
times  it  may  be  more  punctate  or  blotchy  in  appearance. 
Occasionally  it  is  papular.  The  rash  often  fades  on 
pressure,  but  this  depends  to  some  extent  upon  the 
intensity  of  the  injection.  The  exact  appearance  of  the 
rash  is  by  no  means  constant.  Its  distribution  also 
varies  a  good  deal ;  the  most  common  type  is  a  uniform 
scarlet  rash,  which  appears  simultaneously  all  over  the 
body.  In  some  cases,  however,  the  rash  is  more  limited 
in  its  distribution,  and  may  be  confined  to  the  buttocks 
and  flexor  aspects  of  the  thighs,  or  to  the  skin  over  the 
joints  of  the  extremities,  around  the  ankles,  knees,  and 
wrists.  Most  commonly  the  rash  only  lasts  for  a  few 
days,  and  then  fades  away  ;  occasionally  it  may  persist 
for  a  week  or  even  longer.  Desquamation  often  occurs, 
and  especially  if  the  rash  has  been  at  all  severe.  Slight 
albuminuria  is  sometimes  present  for  a  few  days  in  the 
more  severe  cases. 

In  the  worst  cases  all  the  symptoms  of  septicaemia 
develop,  and  the  patient  soon  sinks  into  a  typhoid  state 
and  dies.  In  the  milder  cases  the  rash  lasts  for  a  few 
days,  accompanied  by  an  elevated  temperature,  but  often 
by  very  few  other  constitutional  symptoms,  and  then 
clears  up,  and  the  patient  makes  a  good  recovery. 
Almost  any  degree  may  be  seen  between  these  two  types 
of  case.  Septic  rashes  are  much  more  often  seen  in 
children  than  in  adults.  In  children  a  very  mild  degree 
of  sepsis  is  often  followed  by  a  rash,  and  frequently  the 
rash  is  almost  the  only  symptom  present.  It  is  quite 
common   to   see  a  child,  as  the  result  of  some  septic 


ii8     The  After-Treatment  of  Operations 

infection,  such  as  the  opening  of  an  abscess  or  the 
presence  of  an  infected  wound,  develop  a  scarlatiniform 
rash  and  perhaps  a  temperature  of  103°  F.,  and  in  twenty- 
four  hours  or  forty-eight  hours  to  see  the  whole  of  the 
rash  disappear  and  the  temperature  come  down  to 
normal. 

As  regards  the  condition  of  the  wound  :  there  are  often 
no  signs  of  sepsis  in  it  at  the  time  when  the  rash 
first  appears ;  it  may  be  a  little  puffy  round  the  edges, 
but  often  there  is  little  more  than  this,  and  sometimes 
there  is  nothing  to  be  seen  at  all.  Later  on  the  wound 
usually  gets  into  a  sloughy  condition,  or  breaks  down 
and  suppurates. 

The  argument  often  used  against  the  diagnosis  of  the 
rash  as  septic,  that  the  wound  does  not  show  signs  of 
sepsis,  or  only  shows  them  slightly,  is  quite  fallacious. 
It  must  be  remembered  that  the  appearance  of  a  septic 
rash  after  an  operation  is  evidence  of  a  general  septic 
infection  in  contradistincton  to  a  local  infection,  and 
that  therefore  the  wound  itself,  Avhich  is  the  site  of 
infection,  does  not  always  break  down  or  show  signs  of 
sepsis. 

General  septic  infection  only  occurs  in  the  cases  where 
the  local  resistance  to  septic  organisms  is  absent  or 
insufficient ;  and  since  pus  in  the  wound  is  the  result 
of  local  resistance,  one  would  not  expect  to  see  the  wound 
break  down  to  any  marked  extent  in  these  cases.  And, 
in  fact,  it  may  be  stated  as  a  rule  that  in  those  cases 
where,  after  an  operation,  general  infection  of  the  blood 
occurs  as  manifested  by  the  appearance  of  a  rash  or  other 
constitutional  symptoms,  the  wound  shows  little  or  no 
evidence  of  sepsis.  And  the  more  severe  the  general 
infection,  and  the  more  rapid  its  onset,  the  less  likely  is 
the  wound  to  show  marked  signs  of  sepsis.     There  is, 


Post-Operative  Rashes  119 

however,  another  class  of  case  in  which  the  wound  first 
breaks  down  and  suppurates,  and  then  later  on,  the  local 
resistance  to  the  action  of  the  septic  organisms  proving 
insufficient  to  protect  the  body  from  general  infection, 
general  infection  takes  place  and  a  rash  develops ;  in  this 
class  of  case  the  rash  will,  of  course,  not  appear  for  some 
time  after  the  operation. 

The  diagnosis  is  often  a  matter  of  very  considerable 
difficulty.  The  conditions  under  which  the  rash  appears 
— that  is  to  say,  within  a  few  days  after  an  operation — 
should  make  one  suspicious  of  sepsis,  and  cases  should 
not  be  called  scarlatina  and  removed  to  a  fever  ward 
without  strong  evidence  in  favour  of  scarlet  fever  and  a 
history  of  possible  infection.  If  there  is  much  doubt  as 
to  whether  the  case  is  one  of  scarlet  fever  or  sepsis,  the 
patient  should  be  isolated  as  far  as  possible  for  a  few  days, 
when  the  diagnosis  will  probably  be  cleared  up.  The 
so-called  strawberry  appearance  of  the  tongue  which  is 
seen  in  scarlet  fever  is  not  seen  in  cases  of  sepsis,  though 
the  tongue  is  furred. 

The  following  are  some  of  the  points  which  may  help 
in  distinguishing  a  septic  from  a  scarlet  fever  rash  : 

1.  The  premonitory  febrile  symptoms  are  usually 
absent,  the  rash  being  the  first  thing  noticed  in  most  cases. 

2.  The  distribution  of  the  rash  is  irregular  ;  it  appears 
often  simultaneously  all  over  the  body,  and  not,  as  in 
scarlet  fever,  on  the  neck  and  face  first. 

3.  There  are  no  throat  symptoms,  except  in  those  cases 
where  the  wound  is  in  the  throat. 

4.  The  pyrexia  is  high  and  of  the  septic  type,  with 
often  marked  intermissions. 

Subsequent  peeling  is  no  proof  of  scarlet  fever,  as  it 
not  infrequently  occurs  in  the  cases  of  undoubtedly  septic 
rash. 


I20    The  After-Treatment  of  Operations 

The  following  are  good  illustrative  cases  of  septic  rash 
following  operations : 

A  child  was  operated  upon  for  curved  tibiae ;  the  right  tibia  was 
divided  on  November  15,  and  the  left  on  the  22nd.  On  the  27th 
the  child  developed  a  scarlet  rash  all  over  the  body.  The  wound 
in  the  right  leg  was  found  to  be  swollen,  and  it  subsequently  broke 
down  and  suppurated.  On  December  i  the  rash  had  cleared  up, 
and  the  patient  was  peeling  freely  all  over  the  trunk  and  right  leg. 
This  child  was  in  a  ward  with  twelve  other  children,  none  of  whom 
developed  scarlet  fever,  so  that  there  could  be  no  doubt  as  to  the 
rash  being  septic. 

A  boy  of  sixteen  had  the  tendons  at  the  back  of  the  ankle  divided 
for  talipes.  Two  hours  after  the  operation  he  had  a  shivering  fit. 
The  next  morning  he  was  hot  and  flushed,  and  had  a  temperature 
of  101°  F.  The  chest  and  limbs  were  covered  with  a  mottled,  rose- 
coloured  rash,  which  disappeared  on  pressure.  Forty-eight  hours 
after  the  operation  the  rash  had  commenced  to  fade  away.  The 
temperature  was  101°  F.  and  the  pulse  126.  On  the  follov/ing  day, 
three  days  after  the  operation,  the  rash  had  disappeared.  The 
temperature  was  100°  F.  On  examining  the  wound,  it  was  found  that 
the  skin  round  it  was  red,  swollen,  and  very  tender,  and  the  foot 
and  ankle  were  oedematous.  On  the  seventh  day  after  the  opera- 
tion all  the  symptoms  had  cleared  up,  and  the  patient  made  a  good 
recovery. 

The  following  is  a  good  example  of  a  doubtful  case,  in 
which  the  diagnosis  was  difficult  : 

A  boy,  aged  six,  had  an  exostosis  removed  from  the  lower  end  of 
the  femur.  Thirty-six  hours  after  the  operation  his  temperature 
went  up  to  ioi"2°  F,  Forty-eight  hours  after  the  operation  the  tem- 
perature had  risen  to  104°  F. ,  and  he  was  in  a  state  of  high  fever,  with 
a  flushed  face,  rapid  pulse  (156),  and  quick,  shallow  respiration. 
The  whole  of  the  body  and  limbs  were  covered  with  a  bright, 
scarlet,  punctiform  rash,  fading  on  pressure,  and  not  elevated  or 
perceptible  to  the  touch.  The  tongue  was  furred  and  the  pharynx 
was  congested.  The  wound  at  this  time  was  swollen  round  the 
edges,  but  otherwise  showed  no  signs  of  suppuration.  On  the 
fourth  day  a  bright  erythematous  patch  was  noticed  on  the  back  of 
the  left  wrist-joint.     On  the  fifth  day  the  rash  was  the  same  as 


Post-Operative  Rashes  121 

before,  but  there  was  in  addition  extreme  hyperaesthesia  over  the 
whole  body,  and  the  patient  complained  of  pain  in  the  wound.  On 
the  sixth  day  a  trace  of  albumin  was  found  for  the  first  time  in  the 
urine.  On  the  eighth  day  both  elbow-joints  were  painful  and 
swollen,  and  the  patient  complained  of  pain  in  the  knees.  At  this 
time  the  wound  was  very  foul  and  sloughy,  and  contained  some 
very  foetid  pus.  On  the  tenth  day  the  rash  had  faded  slightly,  and 
there  was  commencing  desquamation  on  the  chest  and  face.  The 
inguinal  glands  were  enlarged,  and  there  were  pysemic  abscesses  in 
several  places.     The  patient  died  in  the  afternoon. 

At  the  post-mortem  the  elbow-joints  and  knees  were  found  to 
contain  pus,  and  there  were  other  signs  of  pysemia. 

Scarlet  Fever  following  Operations. — There  have 
been  a  considerable  number  of  cases  reported  from  time 
to  time  of  scarlet  fever  following  an  operation.  Many  of 
these  cases  are  certainly  not  scarlet  fever,  but  cases  of 
sepsis  which  have  been  mistaken  for  scarlet  fever.  It  is 
sometimes  extremely  difficult  or  even  impossible  to  dis- 
tinguish between  a  genuine  attack  of  scarlet  fever  follow- 
ing an  operation  and  a  septic  rash.  In  some  of  the 
cases,  however,  other  persons  who  have  been  in  attend- 
ance on,  or  in  contact  with,  the  patient  have  subse- 
quently developed  scarlet  fever,  and  thus  the  infective 
nature  of  the  rash  has  been  conclusively  proved. 

Operations  upon  the  nose  and  throat — such  as  for  the 
removal  of  adenoids,  tonsils,  etc.,  and  operations  for  cleft 
palate — seem  to  be  those  most  commonly  followed  by  an 
attack  of  scarlet  fever.  Quite  a  large  number  of  cases 
seem  to  have  followed  the  operation  for  adenoids.  The 
source  of  infection  has  not  always  been  clear.  In  some 
cases  it  has  afterwards  been  found  that  the  room  or  house 
was  infected,  or  that  the  patient  had  come  into  contact 
with  infected  persons  just  prior  to  the  operation,  or  even 
that  the  operator  was  the  source  of  infection,  as  in  a  case 
quoted  by  Sir  James  Paget. 


122    The  After-Treatment  of  Operations 

The  late  Dr.  Washbourne,  in  an  article  on  this  subject, 
in  which  he  quoted  several  cases,  stated  that  he  thought 
the  organism  or  infective  virus  of  scarlet  fever  remained 
dormant  in  the  mouth,  and  that  the  traumatism  caused 
by  the  operation  allowed  of  its  entry  and  development. 
This  is  a  similar  view  to  that  of  the  late  Sir  James  Paget, 
who  said  that  the  operation,  by  lowering  the  patient's 
resisting  power,  allowed  of  the  development  of  an  other- 
wise dormant  virus. 

Another  view  which  would  seem  a  very  probable  one 
in  many  cases  is  that  the  virus  of  scarlet  fever  finds  an 
entrance  by  the  wound  at  the  time  of  the  operation  in 
the  same  way  that  septic  infection  occurs.  This  view 
will  account  for  the  very  short  incubation  period  in  these 
cases  of  post-operative  scarlatina,  owing  to  the  more 
direct  method  of  entry  of  the  virus  into  the  system. 
That  this  view  is  the  correct  one — in  some  cases,  at  any 
rate — is  supported  by  the  fact  that  occasionally  the  rash 
starts  in  the  neighbourhood  of  the  wound,  and  then 
spreads  over  the  rest  of  the  body. 

The  type  of  scarlet  fever  which  follows  operations  seems 
to  vary  somewhat  from  that  seen  under  ordinary  circum- 
stances, the  characters  of  the  attack  being  apparently 
modified  by  the  conditions  under  which  it  occurs.  Thus 
the  incubation  period  is  often  very  short.  In  a  series  of 
sixty-three  cases  collected  by  Edward  C.  StirHng  the 
commonest  time  for  the  appearance  of  the  rash  was  two 
days  after  the  operation.  The  value  of  this  series  of 
cases  is,  however,  very  doubtful,  as  there  are  a  great 
many  cases  included  in  the  series,  if  not  the  majority, 
that  are  really  septic  cases.  An  analysis  of  the  un- 
doubtedly scarlatina  cases,  however,  shows  that  the  time 
at  which  the  rash  appears  is  often  very  short — two  or 
three  days  in  many  cases,  and  as  short  as  twenty-four 


Post-Operative  Rashes  123 

hours  in  a  few.  Most  of  the  other  variations  that  have 
been  described  seem  to  be  the  result  of  the  inclusion  of 
septic  cases  among  those  of  genuine  scarlet  fever,  and 
therefore  but  little  value  can  be  attached  to  them. 

Rashes  due  to  Enemata. — These  are  not  at  all  un- 
common, and  it  is  most  important  that  they  should  be 
recognised,  as  otherwise  they  may  be  confused  with  septic 
or  scarlatinal  rashes,  and  cause  considerable  confusion. 
The  practice  of  giving  an  enema  just  before  an  opera- 
tion is  now  so  usual  that  it  is  not  uncommon  to  see  a 
rash  follow  an  operation,  and  be  mistaken  for  the  onset 
of  septicaemia  or  scarlet  fever,  when  it  is  really  due  to  the 
enema  that  was  given  before  the  operation.  The  rash 
generally  makes  its  appearance  very  shortly  after  the 
injection,  usually  in  from  three  to  twenty-four  hours. 
The  most  common  time  seems  to  be  about  twelve  hours. 
The  rash  lasts  from  two  to  four  days,  and  then  gradually 
fades  away. 

The  distribution  of  the  rash  is  very  variable ;  it  may 
be  evenly  distributed  over  almost  the  whole  body,  or  it 
may  be  confined  to  certain  parts.  The  buttocks  and 
thighs — especially  about  the  inner  aspects — and  over  the 
sacrum  are  perhaps  the  most  common  places  for  the 
rash  to  appear,  and  it  is  here  that  it  is  usually  best 
marked  and  thickest.  The  rash  often  appears  on  the  face, 
and  sometimes  on  the  arms  and  upper  part  of  the  chest. 

The  type  of  the  eruption  also  varies  a  good  deal. 
Dr.  Monro  describes  three  types  of  rash  from  enemata  : 
(i)  The  scarlatiniform  ;  (2)  the  measly  ;  and  (3)  the  urti- 
carious.  More  than  one  of  these  types  may,  however,  be 
present  at  once,  or  the  rash  may  start  as  one  type  and 
subsequently  change  to  another. 

There  is  usually  no  itching  in  the  first  two  types,  but 
the  urticarious  form  is,  as  a  rule,  accompanied  by  very 


124    The  After-Treatment  of  Operations 

severe  itching.  Very  rarely  desquamation  follows  the 
rash.  The  rash  most  commonly  seen  is  a  bright 
erythema,  which  fades  on  pressure.  It  is  usually  patchy, 
and  often  much  more  distinct  in  some  places  than  others. 
The  spots  are  sometimes  raised,  and  the  similarity  to 
measles  may  be  close.  As  a  rule,  the  rash  is  not  accom- 
panied by  any  pyrexia,  but  occasionally  the  temperature 
is  raised  for  a  time.  In  some  of  the  recorded  cases  the 
onset  of  the  rash  has  been  accompanied  by  sickness  and 
vomiting.  The  diagnosis  is  often  very  difficult  when  the 
rash  first  makes  its  appearance.  The  cause  may,  how- 
ever, be  suspected  when  a  rash  appears  within  twenty- 
four  hours  of  the  administration  of  an  enema,  and  is 
not  accompanied  by  pyrexia  and  other  constitutional 
symptoms. 

The  cause  of  enema  rashes  is  somewhat  doubtful.  It 
appears  to  occur  only  after  large  injections,  and  is  not 
seen  after  the  use  of  suppositories  or  small  enemata. 
Soap  enemata,  and  especially  enemata  made  from  hard 
soap,  seem  to  be  the  most  common  cause  of  the  rash. 
Soft  soap,  when  used  to  make  enemata,  seems  to  be  much 
less  liable  to  give  rise  to  a  rash.  Turpentine  enemata 
also  occasionally  cause  a  rash.  It  has  been  supposed 
that  the  cause  of  the  rash  is  the  absorption  of  faecal 
matter  by  the  intestinal  wall  as  the  result  of  solution  by 
the  enema.  It  appears  more  probable,  however,  that  the 
material  composing  the  enema  is  the  responsible  agent. 
No  treatment  is,  as  a  rule,  called  for.  Subsequent 
enemata  may  cause  a  reappearance  of  the  rash,  or  they 
may  be  quite  unaccompanied  by  any  further  trouble. 
When  there  is  severe  itching,  as  is  often  the  case  in  the 
■articarious  form  of  the  rash,  a  weak  lotion  of  carbolic 
acid  should  be  used  to  bathe  the  skin.  This  will  generally 
relieve  the  itching. 


Post-Operative  Rashes  125 

Illustrative  Cases. — E.  G.,  a  woman,  aged  thirty,  was  operated  on 
for  the  removal  of  a  lipoma  on  January  15.  She  had  been  given 
an  enema  of  hard  soap  and  water  (16  ounces)  five  hours  before  the 
operation.  Three  hours  after  the  operation  she  was  seen  to  be  very 
flushed,  and  on  examination  it  was  found  that  she  had  a  bright  ery- 
thematous rash  on  the  face  and  limbs  and  a  large  part  of  the  trunk. 
There  was  no  itching,  and  there  were  no  symptoms  except  the  rash. 
The  temperature  was  normal.  The  rash  lasted  for  two  days  and 
then  faded  away,  having  entirely  disappeared  by  the  19th. 

Miss  M.  was  given  an  enema  consisting  of  2  pints  of  soap 
and  water  at  g  a.m.  on  November  23.  At  12.30  chloroform  was 
administered,  but  no  operation  was  performed.  At  7  p.m.  the 
same  evening  she  complained  of  headache,  and  had  a  shivering  fit. 
The  temperature  was  normal.  During  the  evening  she  developed 
a  red  rash  on  the  neck  and  greater  part  of  the  trunk,  which  was 
accompanied  by  itching.  During  the  night  the  patient  vomited. 
On  the  following  day  there  was  a  profuse  red  eruption  all  over  the 
body.  The  temperature  in  the  morning  was  99*4°  F.,  and  in  the  even- 
ing it  rose  to  99  "8°  F.  The  pulse  was  also  rapid  (102).  On  the  25th 
the  temperature  was  normal,  and  did  not  again  rise,  and  the  patient 
felt  quite  well.  The  rash  was  still  present,  though  fading.  On  the 
26th  the  patient  was  quite  well,  and  the  rash  had  almost  gone. 

Salicylic  Rash. — There  is  a  peculiar  rash  sometimes 
seen  when  saHcylic  wool  has  been  used  as  a  dressing. 
This  rash  only  occurs  on  those  parts  of  the  skin  with 
which  the  wool  has  come  into  direct  contact,  and  its 
distribution,  therefore,  corresponds  to  the  area  of  the 
dressing,  and  thus  renders  its  nature  immediately 
apparent.  The  rash  usually  consists  of  numbers  of 
small  clear  vesicles,  which  may  have  an  inflamed  base. 
The  rash  is  not  accompanied  by  itching.  It  soon  dis- 
appears if  the  salicylic  wool  is  changed  for  sal  alembroth 
or  plain  wool. 

Herpes  following  Operations. — Several  cases  have 
been  recorded  where  an  attack  of  herpes,  accompanied 
by  a  high  temperature,  has  followed  an  operation  or  even 
the  passage  of  instruments  into  the  bladder.     In  most  of 


126    The  After-Treatment  of  Operations 

the  cases  the  herpes  made  its  appearance  in  crops  of 
vesicles  on  the  neck  and  face,  and  around  the  mouth. 
In  many  of  the  cases  there  appears  to  have  been  some 
septic  infection. 

Ether  Rash. — This  rash  often  makes  its  appearance 
during  the  administration  of  ether.  It  is  a  bright  roseolous 
rash,  and  best  seen  on  the  face  and  chest,  though  often 
also  present  on  the  limbs.  It  usually  disappears  very 
quickly. 

Erysipelas. — This  is  now  a  very  rare  sequel  to  opera- 
tions, but  is  still  sometimes  seen. 

Drug"-Poisonmg". 

Cases  of  poisoning  from  the  excessive  use  of  antiseptics 
have  been  recorded  from  time  to  time,  and  the  possibility 
of  such  an  occurrence  should  be  borne  in  mind.  These 
cases  often  give  rise  to  a  great  deal  of  difficulty  in 
diagnosis,  as  the  symptoms  are  often  put  down  at  first  to 
some  complication  of  the  operation,  and  poisoning  is  not 
suspected.  Many  of  the  cases  follow  the  use  of  dressings 
saturated  with  strong  antiseptics  and  kept  damp  by 
placing  oil-silk  or  jaconet  over  them,  such,  for  instance, 
as  may  be  used  for  preparing  the  skin  previous  to  opera- 
tion. Of  course,  the  larger  the  area  of  skin  so  covered, 
and  the  longer  the  time  that  the  skin  is  subjected  to  the 
action  of  the  antiseptic,  the  more  pronounced  will  be  the 
result. 

Poisonous  symptoms  may  follow  the  packing  of  large 
cavities  with  antiseptic  gauze  or  washing  out  large 
cavities  with  strong  antiseptic  solutions,  especially  if 
care  is  not  taken  to  remove  the  antiseptic  afterwards. 
Poisonous  symptoms  are  much  more  liable  to  follow  the 
use  of  antiseptics  in  children  than  in  adults,  and  patients 
whose  kidneys  are  not  working  properly  are  more  prone 


Drug-Poisoning  127 

to  develop  symptoms  from  comparatively  small  quantities 
of  antiseptics  than  those  whose  renal  organs  are  sound. 
Again,  some  individuals  seem  much  more  susceptible  to 
certain  drugs  than  others. 

Iodine  Solution.— This  also  causes  blistering  of  the 
skin,  resulting  in  the  epidermis  peeling  off  over  most  of 
the  area  to  which  the  iodine  has  been  applied.  Iodine 
should  not  be  applied  to  the  scrotum  or  to  areas,  such  as 
the  axillae,  where  the  skin  is  very  loose.  Where  blistering 
has  occurred,  the  best  dressing  is  sterilized  stearate  of 
zinc  powder  or  sterilized  vaseline. 

Iodoform  Poisoning. — This  may  follow  the  packing  of 
a  large  cavity  with  iodoform  gauze  or  the  use  of  iodoform 
emulsion  in  the  treatment  of  tubercular  joint  affections. 
The  chief  symptoms  in  the  acute  cases  are  a  very  high 
temperature  (104°  to  107°  F.),  accompanied  by  cerebral 
disturbance,  either  in  the  form  of  delirium,  mania,  or 
coma.  The  pulse  is  rapid,  and  in  the  fatal  cases  the 
patient  soon  passes  into  a  condition  of  collapse,  followed 
by  coma  and  death.  In  addition,  the  pupils  are  generally 
contracted,  and  there  may  be  haemorrhage  from  the 
rectum.  The  symptoms  usually  come  on  within  twenty- 
four  hours.  In  the  chronic  cases  there  is  disturbance 
of  digestion,  loss  of  appetite,  insomnia,  vertigo,  with  a 
rapid  pulse  and  a  raised  temperature. 

As  soon  as  the  symptoms  show  themselves,  any  iodo- 
form-gauze  packing,  if  present,  should  be  removed  and 
the  cavity  washed  out  with  a  solution  of  bkarbonate  of 
potash,  which  is  said  to  act  as  an  antidote.  The  same 
drug  may  also  be  given  by  the  mouth. 

Illustrative  Case. — F.  W.,  aged  fifty-two,  was  operated  upon  for  a 
large  hydronephrosis  of  the  right  kidney.  The  kidney,  or  what  was 
left  of  it,  was  shelled  out  of  its  capsule  as  the  intestines  and  other 
viscera  were  firmly  adherent  to  the  latter.     The  walls  of  the  cavity 


128     The  After-Treatment  of   Operations 

were  stitched  to  the  edges  of  the  abdominal  wound,  and  the  cavity 
itself  was  packed  with  iodoform  gauze.  A  very  large  quantity  of 
the  gauze  had  to  be  used.  The  operation  was  a  very  severe  one, 
but  the  patient  rallied  as  well  as  could  be  expected,  after  being 
transfused  with  normal  saline  and  having  an  injection  of  strychnine. 
Next  day  she  was  comfortable,  and  her  condition  was  good.  Her 
urine  was  normal,  containing  no  albumin,  and  being  normal  in 
quantity  as  far  as  could  be  estimated. 

At  11.30  p.m.  her  pupils  were  noticed  to  be  contracted.  Up  to 
this  time  she  had  had  no  morphia.  Later  in  the  evening  an 
injection  of  ^  grain  of  morphia  was  given  to  secure  sleep  and 
allay  the  restlessness  which  was  present.  She  slept  all  night,  but 
at  5  a.m.  her  temperature  was  found  to  be  105°  F.,  and  she  was 
drowsy  and  could  not  be  aroused.  The  pulse  was  very  rapid,  and 
there  was  some  twitching  of  the  muscles  of  the  face.  The  pupils 
were  still  more  contracted  than  on  the  previous  evening.  At  7  a.m. 
the  temperature  was  107°  F.  This  was  reduced  by  sponging  to 
102°  F.  She  was  very  hot  and  perspiring  freely.  The  pulse  was 
almost  imperceptible,  and  very  fast.  There  was  marked  twitching 
of  the  fingers  and  facial  muscles.  She  had  some  haemorrhage  from 
the  rectum.  The  case  was  thought  to  be  one  of  iodoform  poisoning, 
and  the  gauze  was  all  removed  from  the  wound,  and  the  cavity 
washed  out  with  a  solution  of  potassium  bicarbonate  (20  grains 
to  the  ounce).  She  also  had  20  grains  by  the  mouth.  The 
temperature  again  went  up  to  104°  F. ,  and  remained  up  till  death, 
which  took  place  a  few  hours  later  from  heart  failure. 

Carbolic  Acid  Poisoning. — The  symptoms  usually 
come  on  within  a  few  hours  of  the  application  of  the 
dressing  or  compress ;  the  initial  symptoms  are  commonly 
drowsiness  and  pallor.  The  respirations  are  markedly 
affected  as  a  rule,  there  may  be  dyspnoea,  or  the  breath- 
ing may  be  laboured  or  stertorous — the  chief  symptoms 
seem  to  be  due  to  the  action  of  the  drug  on  the  central 
nervous  system — sooner  or  later  there  is  complete  coma 
with  muscular  relaxation  :  the  pupils  may  be  contracted 
or  normal.  The  urine  is  turned  a  dark  olive-green  colour, 
and  its  specific  gravity  is  increased.  It  is  said  that  a 
premonitory  sign  of  poisoning  is  the  disappearance  of 


Drug-Poisoning  129 

sulphates  from  the  urine,  the  absence  of  all  sulphates 
being  a  sign  of  danger.  The  prognosis  is  favourable,  the 
symptoms  usually  passing  off,  after  the  cause  has  been 
removed,  in  the  course  of  a  day  or  two. 

Lysol,  if  used  too  strong,  may  also  cause  symptoms  of 
carbolic  acid  poisoning,  and  I  have  known  it  produce 
these  symptoms  when  used  as  an  enema. 

Illustrative  Case. — The  pa: lent  was  a  child,  aged  Tour  years.  An 
operation  was  going  to  be  performed  to  get  rid  of  the  deformity 
of  genu  valgum,  and  to  prepare  for  this  the  skin  of  both  legs  was 
thoroughly  cleaned  up  and  a  compress  of  i  in  40  carbolic  acid 
applied  to  most  of  the  skin  of  the  lower  extremities.  Six  hours 
later  it  was  noticed  that  the  child  was  rather  sleepy,  but  nothing 
was  thought  of  it.  Soon  after  this  it  was  found  that  the  child 
was  in  a  comatose  condition.  She  could  not  be  aroused,  and  the 
muscles  were  relaxed.  There  was,  however,  slight  response  to 
stimulation.  The  skin  was  cold  and  very  pale.  Respiration  was 
rather  rapid — about  36.  The  pulse  was  iSo.  The  knee-jerks 
were  absent.  The  pupils  were  normal  in  size,  and  reacted  to  light. 
Some  urine  which  was  drawn  off  was  found  to  be  of  a  greenish 
colour  and  of  a  specific  gravity  of  1,022. 

Carbolic  acid  poisoning  was  diagnosed,  and  the  compresses 
removed.  Saline  purgatives  were  administered  and  stimulants 
given.  Recovery  took  place  slowly  in  the  course  of  about  two 
days,  but  the  urine  remained  green  and  the  pulse  rapid  for  a 
day  or  so. 

Perchloride  and  Biniodide  of  Mercury  Poisoning. 
— The  symptoms  are  the  ordinary  ones  of  ptyalism. 
There  is  generally  marked  gastro-intestinal  disturbance, 
especially  diarrhoea ;  vomiting  may  also  be  present. 
Salivation  is  often  a  marked  symptom.  Suppression  of 
urine  sometimes  occurs,  and  is  a  very  dangerous  com- 
plication. The  pulse  is  feeble  and  quick.  The  symptoms 
often  vary  very  considerably  in  different  cases,  but  if  the 
condition  is  thought  of,  there  is  seldom  any  great  difficulty 
in  arriving  at  a  correct  diagnosis.     The  treatment  should 

9 


130     The  After-Treatment  of  Operations 

be  directed  to  washing  ihe  drug  out  of  the  system  by  the 
use  of  sahne  purgatives  and  large  draughts  of  fluids.' 

Poisoning  from  Strychnine  or  Nux  Vomica. — 
This  may  occur  if  large  repeated  doses  of  strychnine 
have  been  used  to  treat  shock.  As  the  patient  recovers 
from  the  shock  the  drug  begins  to  act,  and,  having  a 
cumulative  action,  produces  poisoning  symptoms. 
Apart  from  overdosage,  hovs^ever,  there  are  certain 
individuals  who  are  peculiarly  susceptible  to  even  small 
doses  of  nux  vomica.  Such  individuals  get  violent 
purging  and  other  alarming  symptoms  if  this  drug  is 
administered.  I  remember  the  case  of  a  man  who  had 
been  operated  upon  for  piles,  in  whom  a  single  dose  of  a 
tonic  containing  5  minims  of  tincture  of  nux  vomica 
produced  violent  purging  and  severe  constitutional 
symptoms.  A  minute  dose  of  strychnine  given  to  this 
patient  on  another  occasion  caused  the  same  result.  I 
have  also  seen  other  similar  cases. 

It  is,  of  course,  not  possible  to  prevent  this,  but  when 
a  patient  after  an  operation  develops  inexplicable 
symptoms,  one  of  which  is  purging,  it  is  advisable  to 
inquire  if  strychnine  in  any  form  is  being  given. 

The  remedy  is,  of  course,  to  stop  the  drug  and  give 
morphia. 


REFERENCES. 


'  Observations  on  Certain  Eruptions  of  the  Skin  which  occur  after 

recent  Operations  or  Injuries ' :  Edward  C.  Stirling,  St.  George's 

Hospital  Reports,  1879. 
'  Six  Cases  of  Rash  after  Enemata ' :  T.  R.  Monro,  Glasgow  Medical 

Journal,  1899. 
'  Scarlet  Fever  following    Operations  ' :  Dr.    Washbourne,  Clinical 

Journal,  October  15,  1902. 
'Sir  James  Paget's  Lectures  and  Essays,'  p.  349. 


CHAPTER  IX 

OPERATIONS    ON    THE    MOUTH,   NOSE,   AND 
PHARYNX 

Removal  of  Adenoids. 

Complications. — (i)  Severe  sepsis,  followed  occasionally 
by  septic  pneumonia ;  (2)  severe  septic  throat  due  to 
diphtheria  or  scarlet  fever  ;  (3)  septic  rash  ;  (4)  acute 
otitis  media. 

Complications  after  an  operation  for  the  removal  of 
adenoids  are  but  rarely  seen,  but  when  they  occur  they 
are  often  grave  ;  this  is  all  the  more  unfortunate,  as  the 
operation  is  usually  considered  to  be  a  very  simple  one. 
In  order  to  avoid  these  complications  as  far  as  possible, 
it  is  particularly  desirable  that  the  patient  should  not  be 
operated  upon  unless  the  throat  is  in  good  condition  at 
the  time,  and  the  patient  has  not  recently  been  exposed 
to  the  bad  effects  of  unhealthy  surroundings,  or  is  likely 
to  be  exposed  to  them  afterwards.  With  this  object 
in  view  it  is  an  excellent  plan  to  have  any  bad  and 
especially  septic  teeth  removed  before  the  operation,  and 
to  let  the  patient  have  the  throat  sprayed  with  some 
suitable  antiseptic  for  a  day  or  two  previous  to  the 
operation.  The  greatest  care  should  always  be  taken  to 
see  that  the  patient  has  not  recently  been  subjected  to 
any  risk  of  catching   scarlet  fever,  diphtheria,  or  any 

I3i 


132     The  After-Treatment  of  Operations 

other  fever.  After  the  operation  is  over  the  patient 
should  be  kept  in  bed  for  twenty-four  hours,  and  provided 
with  plenty  of  clean  pocket-handkerchiefs  on  which  to 
blow  his  nose.  It  is  advisable  in  private  cases  to  warn 
the  parents  that  the  child  may  vomit  some  blood  occa- 
sionally for  the  first  twenty-four  hours,  as  otherwise  this 
may  give  rise  to  the  idea  that  the  child  is  bleeding,  and 
cause  considerable  alarm.  Care  must  be  taken  to  see 
that  the  patient  is  not  put  in  a  draught ;  a  stuffy  room  is, 
however,  to  be  particularly  avoided.  Some  light  food 
may  be  given  in  about  two  hours  after  the  operation. 
No  particular  diet  is  necessary,  but,  as  a  rule,  semi- 
solids, such  as  custard,  bread-and-milk  (boiled),  thick 
soups,  etc.,  are  more  easily  swallowed  than  fluids.  On 
the  day  following  the  operation  the  throat  should  be 
sprayed  with  some  suitable  antiseptic,  such  as  one  of  the 
following :  ' 

9 


9 


or,  if  the  patient  is  old  enough,  he  should  be  made  to  use 
the  same  solution  as  a  gargle;  this  helps  to  get  rid  of  any 
accumulated  blood  or  mucus  at  the  back  of  the  throat, 
and  at  the  same  time  tends  to  keep  the  latter  free  from 
infective  material.  The  throat  should  be  sprayed  or 
gargled  before  and  after  each  meal  for  the  first  week  after 
the  operation.  Anything  in  the  way  of  syringing  or 
spraying  the  naso-pharynx  is  generally  better  avoided,  as 
it  increases  the  danger  of  middle-ear  trouble. 


Sodse  sulph.     - 

Si.ss. 

^ 

Sodae  sulph. 

3ii. 

Hydr.  iodidi  rubri  - 

grs.  ii. 

Sodae  bicarb. 

grs.  X. 

Sodae  iodidi     - 

grs.  ii. 

Glycerine  of  car- 

Aquam destill. 

ad  Oi. 

bolic  acid 
Aquam  destill.      - 

111X1. 

ad  Oi. 

Sodae  sulph.     - 

3i- 

Sanitas    - 

5iii. 

^ 

Listerine 

5iii. 

Aquam  destill. 

ad  Oi. 

Aquam  destill. 

ad  Oss, 

Mouth,  Nose,  and  Pharynx         13J 

If  it  is  thought  advisable  to  syringe  the  naso-pharynx, 
care  must  be  taken  that  the  fluid  is  not  injected 
forcibly,  and  that  a  free  exit  is  allowed  for  its  escape. 
Mr.  Sheild  advises  that  a  syringe  of  about  5-ounce 
capacity  should  be  used,  with  a  piece  of  rubber  tubing  of 
small  diameter  attached  to  its  end.  The  tubing  should 
be  passed  along  the  floor  of  the  nose,  and  should  fit  the 
nares  quite  loosely.  He  also  recommends  allowing  the 
patient  to  inhale  the  vapour  of  creosote,  iodine,  or  carbolic 
acid  from  one  of  the  usual  forms  of  apparatus,  two  or 
three  times  a  day,  after  an  operation  on  the  nose  or 
throat. 

A  saline  purge  should  be  administered  on  the  day 
following  the  operation,  and  repeated,  if  necessary.  The 
patient  may  be  allowed  to  get  up  on  the  day  after  the 
operation  in  uncomplicated  cases,  but  should  be  confined 
to  one  room,  if  possible,  for  two  or  three  days.  For  the 
first  day  or  so,  and  sometimes  for  a  week  after  the  opera- 
tion, the  symptoms  of  nasal  obstruction  often  persist, 
owing  to  the  swelling  of  the  mucous  membrane  which 
takes  place.  At  the  end  of  this  time,  however,  it  is  of 
great  importance  to  make  the  child  do  regular  respiratory 
exercises,  so  that  he  may  get  accustomed  to  breathing 
properly  through  the  nose.  The  child  should  be  made 
to  close  the  mouth  and  breathe  entirely  through  the  nose 
for  five  or  ten  minutes  at  a  time  ;  this  should  be  done 
two  or  three  times  a  day,  and  the  child  encouraged  to 
breathe  as  much  as  possible  through  the  nose  at  all 
times. 

In  cases  where  it  is  difficult  to  get  the  patient  to  do 
this  properly,  owing  to  lack  of  intelligence,  etc.,  a  good 
plan  is  to  fix  a  piece  of  oil-silk  over  the  mouth  by  tapes 
round  the  head,  for  an  hour  or  so  daily,  so  as  to  oblige 
the  child  to  breathe  through  the  nose.     These  exercises 


134    The  After-Treatment  of  Operations 

must  be  continued  until  the  child  has  got  into  the  way  of 
carrying  out  normal  respiration  with  the  mouth  shut.  If 
previous  to  the  operation  the  child  has  got  into  the  habit 
of  pronouncing  words  in  a  nasal  manner,  as  is  almost 
always  the  case  when  there  is  pronounced  obstruction, 
he  must  be  carefully  taught  to  pronounce  these  words 
properly,  repeating  them  over  and  over  again  until  the 
proper  sound  is  obtained.  The  importance  of  these 
exercises  of  breathing  and  speaking  must  not  be  under- 
estimated ;  children  who  have  suffered  from  adenoids  for 
any  length  of  time  have  contracted  the  habit  of  breathing 
through  the  mouth  and  speaking  in  an  incorrect  manner, 
and  it  is  not  to  be  expected  that  the  mere  removal  of  the 
growths  will  remedy  all  this  unless  care  and  patience  are 
exercised  in  breaking  the  child  of  the  habit.  And,  more- 
over, it  is  only  by  carefully  teaching  the  child  nasal 
breathing  and  stopping  habitual  mouth  breathing  that 
any  guarantee  against  a  recurrence  of  the  adenoids  can 
be  secured. 

If  the  naso-pharynx  becomes  septic,  accompanied  by 
foul-smelling  breath,  and  perhaps  a  high  temperature, 
the  naso-pharynx  should  be  irrigated  with  a  nasal  douche 
two  or  three  times  a  day,  warm  water,  or  water  to 
which  a  little  bicarbonate  of  soda  has  been  added,  being 
used  for  the  purpose ;  the  fluid  must  not  be  allowed  to 
flow  in  under  pressure,  but  should  flow  gently  in  at 
one  nostril  and  out  at  the  other,  the  patient  being  in- 
structed to  breathe  through  the  mouth  meanwhile.  A 
purge  should,  of  course,  be  administered  at  once,  and 
small  doses  of  quinine  and  iron  are  sometimes  useful. 

If  symptoms  of  otitis  media  develop  after  the  operation, 
a  blister  or  leeches  should  be  at  once  applied  behind  the 
affected  ear,  or  hot  fomentations  repeatedly  applied  to 
that  side  of  the  head.     The  naso-pharynx  must  also  be 


Mouth,  Nose,  and   Pharynx         135 

irrigated.  If  suppuration  occurs  in  the  ear,  the  case 
must  be  treated  as  an  ordinary  case  of  otitis  media. 

Children  who  have  just  undergone  the  operation  for 
adenoids  seem  especially  liable  to  catch  diphtheria  or 
scarlet  fever  if  they  are  subjected  to  any  infection,  and 
when  they  contract  one  of  these  diseases  under  such 
circumstances  it  is  a  very  serious  matter.  Care  must, 
therefore,  be  exercised  to  prevent  as  far  as  possible  any 
chance  of  the  child  contracting  them.  An  attack  of 
influenza  may  supervene  upon  an  operation  for  adenoids, 
and  when  this  occurs  there  may  be  considerable  difficulty 
in  correctly  diagnosing  the  symptoms,  which  may  be  very 
alarming  at  first. 

The  appearance  of  a  rash  after  an  operation  for  the 
removal  of  adenoids  or  tonsils  seems  to  be  commoner  than 
is  generally  supposed.  In  an  analysis  of  sixty  such  cases 
made  by  Dr.  Wyatt  Wingrave,*  he  found  that  a  rash 
appeared  in  about  2  per  cent,  of  all  cases  of  operation  for 
tonsils  or  adenoids.  In  only  four  out  of  the  sixty  cases 
was  the  rash  proved  to  be  scarlet  fever,  in  one  case  it 
was  diphtheritic,  and  in  the  remainder  it  appears  to  have 
been  septic  in  origin.  In  a  large  number  of  the  cases 
the  rash  was  not  accompanied  by  any  other  constitutional 
symptoms  of  sepsis.  The  rash  generally  appears  on  the 
second  or  third  day,  and  lasts  about  four  days.  In  four 
out  of  the  sixty  cases  the  rash  was  followed  by  acute 
inflammation  of  the  cervical  glands. 

On  the  fourth  or  fifth  day  after  the  operation  the 
Eustachian  tube  should  be  irflated  by  means  of  Polit- 
zer's  bag,  and  this  should  be  repeated  daily  for  three  or 
four  days,  and  for  longer  in  cases  where  there  is  any 
marked  deafness  associated  with  the  adenoids.  Or,  if 
the  child  is  old  and  intelligent  enough  to  understand,  he 
*  Medical  Press  and  Circular,  January  27,  1904. 


136     The  After-Treatment  of  Operations 

may  be  shown  how  to  inflate  the  Eustachian  tubes  for 
himself  by  holding  his  nose  and  forcing  the  air  into  his 
pharynx.  Of  course,  if  there  is  any  sepsis  after  the 
operation,  the  use  of  the  Politzer's  bag  must  be  deferred. 
In  all  bad  cases  of  adenoids  it  is  a  good  thing  to  insist  on 
the  child  doing  daily  respiratory  exercises,  with  deep 
breathing,  for  some  months  after  the  operation. 

Removal  of  Tonsils. 

The  complications  are  practically  the  same  as  in  the 
case  of  adenoids,  except  that  otitis  media  does  not  occur. 
The  after-treatment  is  also  the  same.  As  in  the  case  of 
adenoids,  the  throat  should  be  sprayed  for  the  first  few 
days  after  the  operation  at  frequent  intervals.  Gargling 
is  usually  impossible,  as  the  throat  is  too  sore.  On  this 
account  also  swallowing  is  more  painful,  and  while  this 
is  the  case  the  patient  should  be  given  such  things  as 
jellies,  custard,  bread-and-milk,  etc.,  as  these  are  often 
swallowed  more  easily'  than  fluids.  A  condition  very 
closely  resembling  ordinary  follicular  tonsillitis  sometimes 
occurs  on  the  raw  surface  after  the  removal  of  the  tonsils. 
It  should  be  treated  as  for  that  afl"ection  by  chlorate  of 
potash,  gargles,  etc.  Chlorate  of  potash  internally  is 
often  very  useful  in  these  cases : 

^     Pot.  chlor.  -  -  -  -  -     gr.  V. 

Aquam  menth.  pip.       -  -  -  -     ad  gi. 

Sig. ;  Three  times  a  day. 

or  the  following  mouth-wash  may  be  used,  and  some  of 
it  swallowed  : 

1^    Pot.  chlor.  -  -  -  -  -  gr.  vii. 

Tinct.  ferri  perchlor.  ...  -  mx. 

Glycerini  -  -  -  •.  -  5i- 

Aquam  luenth.  pip.  -  -        .    -  -  ad  gi. 


Mouth,   Nose,   and    Pharynx         137 

There  is  one  point  of  considerable  importance  in  the 
after-treatment  of  both  adenoids  and  tonsils  which  must 
be  kept  in  mind  :  the  patients  are  often  in  weak  health, 
and  the  enlargement  of  their  tonsils,  etc.,  is  largely  the 
result  of  their  constitutional  condition,  and  therefore  care 
must  be  taken  after  the  operation  to  improve  their  general 
health.  If  possible,  they  should  be  sent  away  for  a 
change  of  air,  preferably  to  the  seaside,  as  soon  as  they 
have  recovered  from  the  operation — i.e.,  in  about  a  week 
or  ten  days'  time. 

Tooth  Extraction,  etc. 

It  is  not  usually  considered  necessary  to  pay  any  atten- 
tion to  the  wound  after  the  extraction  of  teeth,  except  in 
the  event  of  haemorrhage  proving  troublesome.  This 
carelessness  is  not,  however,  justified  ;  sepsis  not  infre- 
quently occurs,  and  there  are  many  recorded  cases  where 
the  most  serious  results  have  followed  from  this  cause. 
Lately,  considerable  attention  has  been  paid  to  oral  sepsis 
and  its  results,  and  it  seems  probable  that  it  is  answer- 
able for  many  more  diseases  than  had  previously  been 
supposed.  Some  attempt,  therefore,  should  be  made,  by 
the  constant  use  of  mouth-washes,  etc.,  to  keep  the  mouth 
clean  for  the  first  two  or  three  days  after  teeth  have 
been  extracted.  One  of  the  best  preparations  for  this 
purpose  is  phenate  of  soda  (about  i  drachm  to  the  pint). 
This  has  the  double  advantage  of  keeping  the  mouth 
clean  and  relieving  the  pain  after  extraction.  A  solution 
of  tincture  of  arnica,  which  is  very  popular,  can  also  be 
used,  but  is  not  so  efficacious  as  phenate  of  soda.  A 
very  excellent  mouth-wash  in  all  septic  conditions  of  the 
mouth,  and  one  which  can  be  used  after  extraction,  is  the 
following : 


38     The  After-Treatment  of  Operations 


Alcohol 

. 

- 

-     100  parts 

Tinct.  rhatany 

- 

. 

-      40     ., 

Acid,  benzoic. 

. 

. 

8     ,, 

Saccharine  - 

. 

. 

4     .. 

Olei  menth.  pip. 

- 

h  part 

Olei  cinammomi 

- 

- 

-       h    .. 

Sig. :  Fifty  drops 

to  half  a  pint 

of  water. 

Operations  on  the  Tongue,  etc. 

Complications. — (i)  Sloughing  and  haemorrhage  ; 
(2)  septic  pneumonia ;  (3)  oedema  of  the  glottis ;  (4) 
cellulitis,  etc. 

A  certain  amount  of  sepsis  often  accompanies  these 
operations,  and  is  quite  unavoidable  ;  but  much  may  be 
done  to  reduce  it.  It  is  very  important  that  before  the 
operation  any  decayed  or  septic  teeth  should  be  removed, 
and  the  mouth  and  throat  well  washed  out  with  some 
suitable  mouth-wash  for  several  days  prior  to  the 
operation.  The  most  effectual  way  of  keeping  the 
mouth  clean  after  operations  upon  the  tongue  is  to  make 
the  patient  lie  right  over  on  his  side,  so  that  the  fluid 
cannot  get  into  his  throat,  and  then  to  gently  irrigate  the 
oral  cavity  with  warm  boracic,  or  other  suitable  solution. 
(Mr.  Jacobson  advises  i  in  60  or  80  carbolic  to  be  used.) 
If  this  is  done  with  care,  the  mouth  and  stump  of  the 
tongue  can  be  very  effectually  cleansed  without  any 
discomfort  to  the  patient,  and  without  causing  coughing. 
The  irrigator  should  be  provided  with  a  glass  nozzle,  and 
very  little  pressure  should  be  used.  A  syringe  may  be 
used  instead,  if  desired.  The  mouth  should  be  frequently 
irrigated  out  in  this  way  during  the  first  few  days  after 
the  operation.  After  this  the  patient  may  rinse  the 
mouth  out  for  himself  in  the  ordinary  way.  The 
alcoholic  mouth-wash  already  mentioned  (under  '  Extrac- 
tion ')  is  a  very  good  one  in  these  cases.     Mr.  Jacobson 


Mouth,   Nose,  and   Pharynx         139 

advises  painting  the  stump  over  every  two  or  three  hours 
with  a  solution  of  formalin.  The  patient  should  be  nursed 
in  a  sitting  position,  well  propped  up  with  pillows. 
This  position  tends  to  prevent  congestion  of  the  lungs, 
and  also  prevents  the  stump  of  the  tongue  falling  back 
and  obstructing  the  air-passage,  which,  if  it  has  been 
freely  cut  away  from  the  floor  of  the  mouth,  it  is  apt  to 
do  in  the  prone  position. 

The  patient  should  be  fed  after  the  operation  by 
means  of  a  feeder  with  about  3  or  4  inches  of  india- 
rubber  tube  attached  to  the  nozzle.  The  end  of  the 
tube  is  passed  to  the  back  of  the  throat,  and  the  feeder 
gently  tilted  up.  For  the  first  day  or  so  the  diet  has  to 
be  fluid  only,  but  after  that  semi-solids  can  usually  be 
taken.  A  calomel  or  saline  purge  should  usually  be 
given  on  the  day  following  the  operation.  For  haemor- 
rhage after  operations  on  the  tongue,  see  p.  66. 


Operations  on  the  Nose. 

All  that  has  been  said  in  connection  with  adenoids 
also  applies  here.  The  treatment  of  haemorrhage  after 
operations  on  the  nose  has  already  been  described  in  the 
chapter  on  haemorrhage.  A  piece  of  gauze  kept  over 
the  nose,  and  damped  occasionally  with  some  volatile 
antiseptic,  is  of  assistance  in  preventing  sepsis  in  some 
cases,  especially  after  removal  of  the  turbinates.  Per- 
sistent sneezing  is  a  curious  complication  that  some- 
times occurs  after  operations  on  the  nose.  This  may 
prove  extremely  troublesome.  If  it  continues  for  any 
length  of  time,  the  best  way  of  treating  it  is  to 
paint  the  nasal  cavity  with  a  solution  of  cocaine,  or 
cocaine  and  suprarenal  extract.  It  may  also  often  be 
stopped   by  simply  syringing    out   the  nose  with  warm 


140     The  After-Treatment  of  Operations 

water.  As  a  rule,  after  operations  on  the  nose,  one  or 
both  nostrils  are  left  plugged.  The  plugs  will  either 
consist  of  gauze  or  pieces  of  rubber  sponge.  The  plugs 
are  generally  removed  in  forty-eight  hours,  and  after  this 
the  patient  is  allowed  to  breathe  through  the  nose.  The 
patient  should  be  told  on  no  account  to  attempt  to  blow 
his  nose  during  the  first  day  or  two.  If  crusts  form  in 
the  nostrils  and  obstruct  the  passage,  they  should  be 
carefully  removed  by  soaking  them  till  they  are  soft,  and 
then  sponged  away. 


CHAPTER  X 
OPERATIONS  ON  THE  HEAD 

Operations  on  the  Brain :  Trephining-,  etc. 

Complications, — (i)  Hernia  cerebri ;    (2)  oedema  of  the 
brain. 

After  any  operation  on  the  brain,  the  patient  must  be 
kept  as  quiet  as  possible,  preferably  in  a  darkened  room, 
and  anything  that  may  tend  to  excite  the  patient,  such 
as  visits  from  friends,  etc.,  prevented.  The  bowels  should 
be  kept  acting  freely  by  the  administration  of  calomel. 
The  use  of  alcohol  in  any  form  must  be  avoided.  In 
cases  of  trephining  for  haemorrhage  on  to  the  dura  mater, 
the  patient  need  not  be  subjected  to  so  much  restraint, 
and,  as  a  rule,  he  may  be  allowed  to  sit  up  soon  after  the 
operation ;  in  these  cases  it  may  be  assumed  that  the 
patient  is  well  as  soon  as  the  wound  has  healed.  In- 
flammation, if  it  occurs  after  these  operations,  will 
usually  show  itself  by  a  high  temperature  and  symptoms 
of  increased  intercranial  tension  on  or  about  the  third  day 
after  the  operation. 

After  operations  in  which  the  dura  has  been  opened, 
drainage  is  generally  provided  for  by  means  of  flat  pieces 
of  thin  'rubber.  These  drains  can  usually  be  removed 
in  twenty-four  hours  after  operation,  unless  sepsis  was 
present  in  the  first  instance. 

141 


142     The  After-Treatment  of  Operations 

If  shock  occurs  after  an  operation  on  the  brain,  it  is 
best  treated  by  small  repeated  doses  of  morphia  rather 
than  by  stimulants. 

After  any  operation  on  the  brain-tissue,  it  is  most 
important  to  insist  on  the  patient  abstaining  from  any 
form  of  mental  strain  for  some  months  after  the  operation. 
At  first  reading  should  be  forbidden,  and  later  only 
allowed  in  moderation.  A  complete  change  and  rest  for 
some  months  is  very  important  in  most  of  these  cases. 

Hernia  cerebri  is  caused  by  unrelieved  tension  in  the 
brain,  and  is  generally  the  result  of  sepsis  ;  the  cause  of 
the  tension  should  therefore  be  investigated,  and,  if 
possible,  removed,  when  the  hernia  will  probably  dis- 
appear. Not  infrequently  pus  will  be  found  in  the 
interior  of  the  hernia,  or  a  superficial  abscess  will  be 
found  beneath  it.  The  hernia  itself  consists  mainly  of 
granulation  tissue,  and  contains  very  little  brain  sub- 
stance, so  that  there  need  be  no  hesitation  in  scraping  it 
away  and  applying  pure  carbolic  acid  to  the  stump.  This 
requires  no  anaesthetic,  as  the  protrusion  is  insensitive. 
The  hernia  may  be  treated  by  applying  pressure  over 
a  piece  of  sterilized  tin-foil. 

Hare-lip  Operations. 

Complications.  —  (i)  Bronchitis  and  pneumonia  ; 
(2)  diarrhoea  ;  (3)  sepsis  ;  (4)  dyspnoea  and  asphyxia. 

A  low  form  of  sepsis  sometimes  occurs  after  these 
operations,  especially  when  it  has  been  necessary  to 
interfere  with  the  bone  in  any  way.  Care  must  be  taken 
to  keep  up  the  strength  of  the  patient  under  these  circum- 
stances, and  to  keep  the  mouth  as  clean  as  possible.  In 
very  young  infants  who  have  had  a  large  cleft  closed  by 
operation  there  is  danger  of  sudden  death  from  asphyxia 


operations  on  the   Head  143 


soon  after  the  operation,  and  this  should  be  borne  in  mind. 
The  nasal  passage  in  young  infants  is  often  too  small  to 
be  used  efficiently  for  respiration,  and  it  easily  becomes 
blocked  up  with  secretion  ;  the  sudden  great  diminution 
in  the  size  of  the  oral  cavity  may  result  in  sudden 
dyspnoea  some  hours  after  the  operation.  Mr.  Jacobson 
cites  three  cases  in  which  fatal  dyspnoea  occurred  from 
this  cause.  The  nurse  should  be  instructed  to  watch  for 
any  difficulty  in  the  breathing,  and  to  depress  the  lower 
lip  of  the  infant  from  time  to  time  so  as  to  allow  of  a  free 
entry  of  air,  or  the  lower  lip  may  be  held  down  by  apply- 
ing a  piece  of  plaster  unAil  the  child  has  had  time  to 
become  accustomed  to  the  new  conditions. 

If  hare-lip  pins  have  been  made  use  of,  they  should  be 
removed  on  the  second  day  after  the  operation  ;  if  fish-gut 
or  silver  wire  has  been  used  for  the  supporting  sutures, 
one  of  them  should  be  re- 
moved on  the  third  day  and 
the  other  left  for  a  day  or 
so  longer.  The  fine  sutures 
used  for  approximating  the 
edges  of  the  wound  should 
not  be  removed  for  a  week, 
unless  they  are  causing 
stitch  abscess,  when  they 
must  be  removed  at  once. 
While  examining  or  re- 
moving stitches,  the  cheeks 
must  be  held  together  so  as  to  prevent  the  wound  being 
subjected  to  any  tension.  After  the  stitches  or  pins  are 
removed,  a  piece  of  adhesive  plaster,  cut  with  a  narrow 
bridge  to  go  over  the  upper  lip,  and  expanded  ends  to 
fit  on  to  the  cheeks,  must  be  put  on  firmly  so  as  to 
bring  the  cheeks  together  and  prevent  any  tension  coming 
on  the  wound  (Fig.  20). 


Fig.  20. 


144    The  After-Treatment  of  Operations 

Cleft  Palate. 

Complications. — (i)  \^'hooping-cough  ;    (2)   exanthe- 
matous  fevers ;  (3)  diarrhoea. 

After  the  operation  the  child's  hands  should  be  secured 
either  by  applying  splints  or  by  wristlets  attached  to 
a  broad  piece  of  webbing  fixed  across  the  bed ;  if  the 
child  can  be  constantly  watched  by  a  competent  at- 
tendant, it  is  better  to  dispense  with  this  restraint, 
as  it  tends  to  make  the  child  restless,  and  may  lead  to 
crying.  Nothing  should  be  given  by  the  mouth  for  three 
or  four  hours  after  the  operation,  and  for  the  first  forty- 
eight  hours  only  barley-water  and  albumin-water  or  milk 
allowed ;  rectal  feeding  may  be  added  if  necessary  after 
this,  and  for  the  first  week  the  diet  should  be  confined  to 
soups,  broth,  egg  and  milk,  etc.,  and  then  jellies,  light 
puddings,  and  food  which  does  not  need  mastication  for 
a  week  more.  If  the  child  is  old  enough  to  understand 
and  do  what  it  is  told,  the  mouth  should  be  syringed  out 
or  sprayed  with  some  mild  antiseptic  lotion  several  times 
a  day.  If  this  procedure  leads  to  any  struggling,  or  the 
child  is  too  young  to  keep  quiet  during  the  process,  it 
must  be  discontinued.  Everything  possible  in  the  way 
of  careful  nursing  must  be  done  to  prevent  the  child 
from  crying  or  being  sick.  If  old  enough  to  talk,  the 
child  must  be  prevented  from  doing  so.  In  three  or 
four  days  after  the  operation,  if  the  weather  is  fine,  the 
patient  should  be  got  out  into  the  open  air  for  an  hour 
or  two  every  day.  It  is  best  not  to  inspect  the  stitches 
at  all  till  the  time  arrives  for  their  removal.  As  a  rule, 
some  of  the  stitches  may  be  removed  at  the  end  of  a 
week  or  ten  days,  and  the  remainder  at  the  end  of  a 
fortnight ;  but  unless  the  stitches  are  causing  sloughing 
or  ulceration,  it  is  well  to  leave  them  as  long  as  possible. 
It  is  usually  about  three  weeks  after  the  operation  before 
the  wound  is  firmly  united. 


Operations  on  the   Head  145 

If  the  operation  has  been  successful  and  the  gap  in  the 
palate  has  been  closed,  the  next  thing  that  calls  for 
attention,  and  which  is  of  the  greatest  importance,  is  to 
teach  the  child  to  pronounce  its  words  properly,  and  this 
is  of  still  greater  importance  if  the  child  has  already 
learnt  to  talk  and  has  got  into  the  habit  of  pronouncing 
words  wrongly.  A  great  deal  of  care  and  patience  is 
often  necessary ;  the  patient  should  be  made  to  sit  on 
a  chair  facing  the  teacher  and  pronounce  words,  and 
especially  those  words  which  he  has  got  into  the  habit 
of  pronouncing  badly,  after  him,  and  at  the  same  time 
watch  the  way  in  which  the  teacher  moves  his  lips  and 
tongue.  The  teacher  should  exaggerate  these  move- 
ments, so  as  to  make  them  more  obvious.  Words  with 
sibilants  and  labials  in  them  should  especially  be  taught 
with  great  care,  as  these  words  are  the  ones  most  likely 
to  be  pronounced  badly  as  the  result  of  the  cleft-palate. 
Nasal  breathing  exercises  should  also  be  carried  out 
daily  to  get  the  child  used  to  breathing  properly  through 
the  nose  when  the  mouth  is  shut  (see  under  Adenoids). 
After  the  Davies-Colley  operation  at  least  three  weeks  and 
often  more  should  be  allowed  to  elapse  before  the  stitches 
in  the  mouth  are  removed  ;  those  in  the  deep  flap  must 
be  left  to  come  out  in  the  best  way  they  can.  Sloughing 
of  the  large  flap  need  not  be  apprehended  in  this  opera- 
tion. 

Artificial  Appliances. 

For  the  Relief  of  Cleft-Palate.  —  An  obturator 
should  only  be  fitted  in  those  cases  where  no  operation 
is  possible,  as,  for  instance,  after  repeated  operations 
have  failed  to  close  the  gap,  when  there  is  not  enough 
tissue  to  close  it,  or  when  the  hard  palate  has  been  suc- 
cessfully operated  upon,  but  owing  to  lack  of  tissue  or 
scar  contraction  it  is  not  possible  to  close  the  gap  in  the 


146    The  After-Treatment  of  Operations 

soft  palate.  In  such  cases  a  properly  fitting  obturator 
is  necessary.  There  are  two  principles  of  fitting  obtu- 
rators— the  Kingsley  method,  in  which  an  ordinary 
vulcanite  or  gold  plate  is  fitted  to  the  hard  palate,  and 
to  the  back  of  this  is  attached  a  soft  rubber  vellum, 
which  fits  into  the  gap  in  the  soft  palate  and  moves  with 
the  palate  muscles  ;  and  the  Seursen  method,  in  which 
there  is  a  fixed  vulcanite  obturator  taking  the  place  of 
the  hard  palate.  In  the  Seursen  method  the  fixed 
obturator  fits  in  between  the  pharyngeal  muscles,  and 
passes  backwards  to  within  ^  inch  of  the  posterior 
pharyngeal  wall ;  when  the  patient  swallows  or  phonates, 
the  muscles  close  round  it  and  shut  off  the  naso-pharynx 
from  the  buccal  cavity.  It  is  fixed  in  place  by  a 
dental  plate  fastened  by  bands  round  some  of  the  upper 
teeth.  The  Seursen  method  is  particularly  adapted  to 
cases  where  the  gap  in  the  soft  palate  is  very  wide. 
Very  good  phonation  can  be  obtained  by  means  of 
these  instruments,  but  to  obtain  good  results  it  is  of 
the  utmost  importance  that  the  patient  should  be  care- 
fully taught  to  speak  after  the  instrument  has  been 
fitted. 

After  the  Removal  of  the  Upper  Jaw.  —  The 
instrument  usually  fitted  in  these  cases  consists  of  a  gold 
or  vulcanite  plate,  to  the  upper  surface  of  which  is 
attached  a  hollow  obturator,  made  so  as  to  fit  into  the 
gap  left  by  the  removal  of  the  jaw ;  the  plate  takes  its 
purchase  from  the  opposite  teeth  and  the  remains  of  the 
hard  palate.  Artificial  teeth  are  fixed  to  the  plate,  so  as 
to  complete  the  upper  set  on  the  side  on  which  the  jaw 
has  been  removed.  These  obturators  are  made  of  gold 
or  vulcanite,  and  should  be  very  smooth,  so  as  not  to 
cause  any  irritation  ;  the  chief  value  of  them  is  in  pre- 
venting the  falling-in    of   the    cheek,  which    is    such   a 


Artificial  Appliances  147 


Fig.  21. — KiNGSLEY  Obturator  for  Cleft  Palate  ;  made 
OF  Soft  Rubber. 


Fig.  22. — Seorsen  Obturator  for  Cleft  Palate  :  made 
OF  Vulcanite. 


Fig.    23. — Obturator  for  Repair  of  the   Hard  Palate  and 
Alveolar  Arch  after  Remoyal  of  the  Left  Upper  Jaw. 


148    The  After-Treatment  of  Operations 

distressing  after-result  in  many  of  these  cases.  By 
restoring  the  roof  of  the  mouth  they  also  help  phonation, 
and  prevent  food  from  getting  into  the  nasal  cavities. 
They  should  be  fitted  as  soon  as  the  wound  has  healed, 
and  before  the  parts  have  had  time  to  contract  and  cause 
deformity. 


CHAPTER  XI 
OPERATIONS  ON  THE  NECK 

Tracheotomy  and  Laryngrotomy. 

Complications. — (i)  Surgical  emphysema ;    (2)  ulcera- 
tion of  the  trachea ;  (3)  sloughing  of  the  wound. 

Surgical  emphysema  is  either  the  result  of  a  faulty 
operation,  or  is  due  to  the  tube  not  being  in  the  trachea. 
If  the  tube  is  properly  in  the  trachea  and  the  air-way 
free,  emphysema  cannot  occur.  When  it  occurs,  the  tube 
must  be  removed  and  carefully  reinserted,  or  a  better 
fitting  one  substituted.  Ulceration  of  the  trachea  is  due 
either  to  the  tube  not  fitting  or  to  its  being  worn  for  too 
long  a  time.  A  metal  tube  should  not  be  left  in  for  more 
than  a  week  without  being  changed  ;  at  the  end  of  that 
time,  if  the  tube  cannot  be  dispensed  with,  a  rubber  one, 
such  as  Morant  Baker's,  should  be  substituted.  Many 
tubes  are  made  with  too  great  a  curve  on  them,  and  the 
lower  end  in  consequence  presses  on  the  anterior  wall 
of  the  trachea  and  causes  ulceration.  The  necks  of 
different  individual's  differ  very  considerably,  and  it  may 
be  necessary  to  try  several  different  tubes  before  one  can 
be  found  to  fit  well.  In  young  children  especially  it  is 
most  necessary  to  get  a  properly  fitting  tube,  as  their 
tissues  will  not  stand  pressure  in  the  same  way  as  adults, 
and  ulceration  is  very  liable  to  occur  from  a  badly-fitting 

tube. 

149 


150    The  After-Treatment  of  Operations 

Sloughing  of  the  Avound  may  be  diphtheritic  or  may 
result  from  the  tube  pressing  too  tightly  against  the 
wound.  The  tapes  should  be  relaxed,  and  the  wound 
dressed  frequently  with  ointment  or  gauze,  a  collar  of 
which  should  be  kept  beneath  the  tube.  If  the  sloughing 
tends  to  spread,  the  wound  should  be  well  painted  with' 
carbolic  acid  or  nitrate  of  silver. 

After  the  operation  the  patient  must  be  put  back  to 
bed,  and  made  as  warm  as  possible.  Most  surgeons 
have  a  steam-tent  put  round  the  bed,  so  as  to  keep  the 
atmosphere  warm  and  moist.  The  value  of  this  is,  how- 
ever, somewhat  doubtful,  as  the  steam  seldom  gets  any- 
where near  the  tube,  and  usually  expends  itself  in  damp- 
ing the  tent.  Fresh  air  is  of  the  utmost  importance,  and 
if  the  temperature  of  the  air  round  the  cot  can  be  kept 
up  to  about  60°  F.  and  the  child  kept  free  from  draughts 
without  the  use  of  the  tent,  it  is  much  better  not  to  use 
one.  Whether  a  steam-tent  is  used  or  not,  the  tempera- 
ture of  the  room  must  be  kept  up  to  60°  or  65°  F.,  and 
all  draughts  avoided  ;  a  double  fold  of  gauze  should  be 
placed  over  the  mouth  of  the  tube,  and  it  is  a  good  plan 
to  drop  a  few  drops  of  eucalyptus  oil  on  to  the  gauze 
from  time  to  time.  If,  however,  this  causes  coughing,  it 
must  be  discontinued.  The  child  should  be  encouraged 
to  go  to  sleep  after  the  operation.  After  the  difficulty 
of  breathing  has  been  relieved  by  the  operation  many 
children  naturally  fall  asleep  for  a  few  hours,  and  they 
should  on  no  account  be  awakened,  as  it  is  the  best 
thing  possible  for  them.  Sleep  is  of  the  greatest  impor- 
tance, as  in  most  cases  the  child  is  very  exhausted  from 
the  previous  difficulty  of  respiration.  The  inner  tube 
must  at  first  be  removed  every  two  hours,  or  oftener 
if  necessary,  but  the  child  should  not  be  awakened  for 
this  purpose.     The  inner  tube  must  be  cleaned  in  weak 


Operations  on  the  Neck  151 

carbolic  solution  (i  in  200)  and  replaced.  Any  mucus  or 
membrane  that  is  coughed  up  should  be  wiped  away  at 
once  with  a  clean  piece  of  turkey-sponge  dipped  in  the 
carbolic  solution.  If  the  tube  becomes  blocked  with  any 
mucus  that  will  not  come  out,  a  soft  feather  may  be  used 
to  remove  it.  The  feather  should,  if  possible,  have  been 
sterilized  by  immersion  in  some  strong  carbolic  solution 
for  an  hour  or  more,  and  then  the  carbolic  washed  away 
with  sterile  water,  or  the  feathers  may  be  sterilized  by 
boiling.  Several  of  these  feathers  should  be  kept  at  hand 
immersed  in  a  weak  carbolic  solution.  The  feather 
should  be  gently  inserted  into  the  tube,  and  then  turned 
round  before  being  removed,  so  as  to  catch  the  mucus,  etc. 
If  the  breathing  becomes  harsh  and  whistling,  and  there 
seems  to  be  difficulty  in  bringing  up  the  secretion,  the 
opening  of  the  tube  must  be  sprayed  with  a  solution  of 
bicarbonate  of  soda  (20  grains  to  the  ounce)  for  five  or 
ten  minutes  at  a  time.  This  will  loosen  the  secretion  or 
membrane,  and  allow  of  its  being  easily  coughed  up,  or, 
if  desired,  the  solution  can  be  applied  to  the  trachea  with 
one  of  the  feathers.  Careful  nursing  is  of  the  utmost 
importance  in  these  cases  ;  it  must  not,  however,  be 
meddlesome.  Especially,  the  child  must  not  be  pre- 
vented from  sleeping. 

The  old  adage  of  '  leaving  well  alone '  is  very  applic- 
able to  these  cases,  and  the  too  free  use  of  the  feather  is 
particularly  to  be  avoided.  If  the  breathing  at  any  time 
becomes  very  difficult  owing  to  the  accumulation  of 
mucus,  etc.,  in  the  trachea  and  tube,  this  can  be  quickly 
relieved  by  sitting  the  patient  up,  and  propping  him  in 
that  position  with  pillows.  Feeding  the  patient  is  usually 
a  difficult  matter,  and  must  be  undertaken  with  care. 
If  possible,  the  patient  should  be  propped  up  in  a  sitting 
position  for  this  purpose,  and  ted  by  means  of  a  feeder 


152    The  After-Treatment  of  Operations 

with  a  piece  of  rubber  tube  attached  to  its  spout,  the  end 
of  which  is  passed  to  the  back  of  the  throat.  The  feed- 
ing must  be  at  frequent  intervals,  and  if  there  is  much 
difficulty  in  getting  the  patient  to  swallow,  nasal  feeding 
must  be  resorted  to  at  once. 

At  the  end  of  the  first  twenty-four  or  thirty-six  hours 
the  outer  tube  must  be  removed  and  cleaned,  or  a  new 
one  introduced.  This  is  usually  an  easy  matter,  but  it 
is  well  to  have  a  director  or  tracheal  dilator  at  hand  in 
case  of  any  difficulty  arising  in  reintroducing  the  tube. 
If  the  original  tube  has  not  got  a  hole  at  the  bend  so  as 
to  allow  a  free  air- way  by  the  mouth,  one  of  these  tubes 
should  be  introduced  at  this  stage  if  obtainable,  or  a 
bivalve  tube  may  be  used.  If  the  inner  tube  of  a  bivalve 
tube  is  removed,  the  patient  can  breathe  through  the 
mouth  if  there  is  no  obstruction.  On  the  second  day 
after  the  operation  the  mouth  of  the  tube  should  be 
blocked  up  either  with  a  wooden  plug  or  with  a  piece  of 
wet  lint  for  ten  or  fifteen  minutes  at  a  time,  so  as  to  get 
the  patient  accustomed  to  breathing  through  the  mouth 
again.  (For  this  purpose  it  is,  of  course,  necessary  to  have 
a  tube  with  an  upper  opening.)  Unless  the  cause  of  the 
obstruction  is  a  permanent  one,  an  attempt  should  be 
made  to  remove  the  tube  altogether  on  the  third  or 
fourth  day. 

Removal  of  the  Tube. — As  stated,  this  should  be  done  at 
the  earliest  possible  date.  A  great  deal  of  trouble  will 
be  saved  if  the  patient  has  been  gradually  accustomed  to 
breathe  through  the  mouth  by  plugging  up  the  opening  of 
the  tube  from  time  to  time.  When  the  tube  is  removed, 
a  pair  of  tracheal  dilators  should  be  at  hand,  so  that 
should  any  difficulty  with  the  breathing  occur,  the  wound 
can  be  quickly  opened.  If  on  removing  the  tube  spasm 
occurs,  the  tube  must  be  reinserted  ;  an  attempt  should 


operations  on  the  Neck  '53 


then  be  made  to  remove  the  tube  while  the  patient 
is  sitting  up  ;  this  will  sometimes  be  successful.  The 
surgeon  should  not  leave  the  patient  after  the  tube  has 
been  removed  until  he  is  satisfied  that  the  patient  is  able 
to  breathe  comfortably  through  the  mouth. 

If  the  tube  has  to  be  retained  for  more  than  a  week,  an 
indiarubber  tube  should  be  substituted  for  the  metal  one  ; 
this  may  be  one  of  Morant  Baker's  tubes,  or  a  very  good 
tube  can  be  constructed  out  of  a  piece  of  drainage-tube 
(see  Fig.  20).  In  infants  especially  a  metal  tube 
should  never  be  retained  for  more  than  a  week.  The 
author  once  saw  a  case  in  an  infant 
under  two  years  of  age  where  a  metal 
tube  had  been  worn  for  a  fortnight, 
and  in  which  the  end  of  the  tube 
ulcerated  into  the  innominate  artery, 
and  the  child  bled  to  death  in  three 
minutes.  In  most  cases  where  there 
is  any  difficulty  in  the  removal  of  the 
tube,  this  is  chiefly  due  to  nervousness 
or  habit  on  the  part  of  the  child,  and 
is  not  due  to  any  actual  obstruction  in 
the  larynx  ;  care  and  patience,  there- 
fore, is  all  that  is  called  for.  Occa- 
sionally, however,  there  is  some  actual 
obstruction  in  the  larynx  from  ad- 
hesion or  granulations,  and  it  becomes  necessary  to 
dilate  the  trachea  above  the  tube ;  this  is,  however,  very 
rarely  the  case.  A  plan  which  is  sometimes  useful  when 
there  is  considerable  difficulty  in  getting  the  patient  to 
breathe  through  the  mouth  is  to  intube  the  larynx,  and 
then  remove  the  tracheotomy-tube,  the  laryngeal-tube 
being  removed  at  the  end  of  twenty-four  or  forty -eight 
hours. 


Fig. 

TO 


24. — Drawing 

SHOW         THE 

Method  of 
MAKING  A  Trache- 
otomy-Tube out 
OF  A  Piece  of 
Drain  age-Tube  . 


154   The  After-Treatment  of  Operations 

Dilating  the  Larynx. — ^A  little  chloroform  is  administered,  and 
after  dilating  the  wound  a  soft  catheter  is  passed  up  from  it,  and 
the  end  drawn  through  the  mouth  with  a  clip ;  several  catheters  of 
increasing  sizes  may  be  in  this  way  passed  through  the  larynx  until 
it  is  sufficiently  dilated,  or  by  means  of  the  catheter  a  silk  thread 
can  be  passed  through  from  the  wound  to  the  mouth,  and  a  small 
piece  of  fine  Turkey  sponge  tied  on  to  the  end  of  the  thread  and 
drawn  up  through  the  larynx  so  as  to  clear  it  or  break  down  any 
adhesions;  or  a  Macewen's  tube  can  be  made  use  of. 

Artificial  Larynx.  —  This  is  an  apparatus  designed 
with  the  object  of  enabHng  a  patient  after  his  larynx  has 
been  removed  to  swallow  without  danger  of  food  getting 
into  the  trachea,  and  at  the  same  time,  by  means  of  a 
reed  fitted  into  the  exit-tube,  enabling  him  to  speak. 
There  are  several  varieties  of  artificial  larynx,  of  which 
probably  Gussenbauer's,  or  Dr.  Foulis's  modification  of 
it,  are  the  best.  They  are  much  too  complicated  for 
description  here.  Some  patients  can  use  them  with 
considerable  success,  but  a  great  many  find  that  they 
can  get  on  better  without;  the  great  difficulty  connected 
with  them  is  that  they  are  very  liable  to  get  blocked  with 
mucus. 

(Esophag-otomy. 

The  chief  difficulty  in  these  cases  is  the  feeding  ;  if 
possible,  this  should  be  done  by  nutrient  enemata  for  the 
first  three  or  four  days,  and  the  patient  not  allowed  to 
swallow  anything  by  the  mouth  during  this  time.  If, 
however,  this  cannot  be  managed,  a  soft  rubber  tube 
must  be  passed  down  the  oesophagus  either  from  the 
mouth  or  nose,  and  the  patient  fed  through  it.  This  tube 
can  either  be  inserted  each  time  the  patient  is  fed,  or,  if 
possible,  it  should  be  retained,  at  any  rate  during  the 
daytime.  At  the  end  of  the  first  week  or  earlier,  if  the 
wound  is  healing  well,  the    patient    may  be  allowed  to 


Operations  on  the  Neck  155 

swallow  liquids  in  small  quantities  at  a  time.  These 
wounds  are  practically  always  septic,  owing  to  organisms 
getting  into  them  from  the  wound,  and  it  is  necessary  to 
see  that  there  is  free  drainage  at  the  most  dependent  part 
of  the  wound  , 

Operations  on  the  Thyroid  Gland. 

Complications. — (i)    Aphonia  ;    (2)    cellulitis    of   the 
neck  ;  (3)  thyroidism  ;  (4)  tetany. 


Fig.  25.^Chart  of  a  Case  of  Thyroidism. 

Aphonia  results  from  wounding  the  recurrent  laryngeal 
nerve,  or  from  its  becoming  involved  in  the  cicatrix.  In 
the  first  case,  the  aphonia  will  come  on  immediately  after 
the  operation,  and  in  the  second,  some  time  afterwards. 

Cellulitis  of  the  neck  is  a  very  serious  complication, 
and  should,  of  course,  not  occur ;  if  it  does,  the  wound 
must  at  once  be  freely  opened  up  and  drainage  pro- 
vided for.  The  possibility  of  thyroidism  occurring  after 
operations  on  the  gland  must  be  borne  iij  mind.     The 


ij6    The  After-Treatment  of  Operatic 


ns 


symptoms  are  similar  to  those  of  exophthalmic  goitre 
(without  the  exophthalmus),  but  are  acute.  They  come 
on,  as  a  rule,  at  the  end  of  the  first  twenty-four  or  forty- 
eight  hours  after  the  operation  ;  the  temperature  goes 
up,  often  to  a  great  height  (103°  to  105°  F.),  and  remains 
intermittent  fFisr.  25)  :  the  patient  becom.es  very  flushed 
and  uncomfortable  ;  the  pulse  is  quick  and  bounding,  and 
there  is  often  marked  tachycardia  ;  the  symptoms  are  very 
alarming,  and  may  easily  be  mistaken  for  the  onset  of 
acute  sepsis.  The  pulse  and  tachycardia  are,  however, 
characteristic,  and  this  mistake  should  not  be  made.  The 
symptoms,  as  a  rule,  subside  in  the  course  of  a  day  or 
two,  and  no  harm  results.  Should  they,  however,  be 
serious,  as  is  sometimes  the  case,  the  wound  must  be 
opened  and  washed  out  thoroughly  with  sterilized  water, 
and  then  drained  or  packed  Avith  gauze  to  prevent  the 
secretion  of  the  gland  getting  into  the  tissues  of  the 
wound  and  being  absorbed  by  the  lymphatics.  In  very 
bad  cases  transfusion  may  be  tried.  This  condition  of 
thyroidism  is  rarely  serious,  but  one  or  two  cases  of  a 
fatal  issue  have  been  recorded.  The  best  method  of  pre- 
venting toxic  symptoms  after  partial  thyroidectomy  is  by 
giving  the  patient  plenty  of  water  and  keeping  the  tissues 
well  flushed  out.  The  practice  at  the  ]\Iayo  clinic, 
where  large  number?  of  these  operations  are  performed, 
is  to  administer  i  quart  of  saline  slowly  per  rectum 
immediately  after  operation,  and  to  repeat  this  twice 
within  the  next  twelve  hours.  If  the  patient  cannot 
retain  these  salines,  the  fluid  should  be  given  subcu- 
taneously.  In  the  earlier  days  of  the  operation,  when  it 
was  the  practice  to  remove  as  much  as  possible  of  the 
gland,  symptoms  like  those  of  myxoedema  not  infrequently 
occurred.  In  these  days,  however,  as  a  rule,  only  one 
lobe  is  removed,  and  this  danger  is  consequentl}-  absent. 
It  may  happen,  however,  that  too  much  of  the  gland  is 


Operations  on  the  Neck  157 

removed,  or  that  the  part  left  is  not  functional,  and  then 
symptoms  due  to  absence  of  thyroid  secretion  may  de- 
velop. The  symptoms  usually  come  on  a  few  days  after 
the  operation,  and  often  take  the  form  of  muscular  spasm. 
Laryngeal  spasm  may  occur,  and  cause  acute  dyspnoea. 
There  may  be  tetany  of  the  hands  and  feet,  and  there  is 
usually  progressive  emaciation.  The  best  treatment  is 
large  doses  of  thyroid  extract,  which  may  have  to  be 
continued  indefinitely. 

Tetany  may  develop  after  an  operation  for  thyroid- 
ectomy, and  will  show  itself  by  attacks  of  tonic  flexion, 
generally  in  the  muscles  of  the  hands.  There  may 
be  general  convulsions  and  high  fever.  The  condition, 
though  alarming,  is  not  fatal.  It  is  due  to  removal  of 
the  parathyroid  glands.  The  best  treatment  is  adminis- 
tration by  the  mouth  of  parathyroid  extract,  or  the 
surgical  implantation  of  a  parathyroid  gland  from  an 
animal  into  the  abdominal  cavity. 

Operation  for  the  Removal  of  Enlargred  Glands. 

After  the  operation  the  patient  should  be  prevented  as 
far  as  possible  from  moving  his  head,  and  if  the  wound 
is  large,  sand-bags  should  be  placed  for  this  purpose  on 
both  sides  of  the  head  and  neck.  In  order  that  the  scar 
may  not  be  unsightly,  the  stitches  should  be  removed  in 
three  or  four  days,  and  the  edges  of  the  wound  supported 
by  strips  of  adhesive  plaster.  If  a  tube  has  been  put  in, 
it  should  be  removed  in  twenty-four  hours.  If,  as  is 
usually  the  case,  the  glands  are  tubercular,  the  patient 
should  be  sent  to  the  seaside  or  to  a  bracing  climate  as 
soon  as  the  wound  has  healed,  and  should  be  kept  there 
for  some  months.  Plenty  of  fresh  air  and  good  food  are 
most  important,  or  more  serious  tubercular  lesions  may 
supervene. 


CHAPTER  XII 
OPERATIONS  ON  THE  THORAX 

Amputation  of  the  Breast. 

Complications. — (i)  Lung  affections  ;  (2)  sloughing  of 
the  skin  ;  (3)  sepsis ;  (4)  fixation  of  the  arm ;  (5)  venous 
stasis  and  oedema  of  the  arm ;  (6)  lymphadenoma. 

If  no  drainage-tube  has  been  used,  the  patient  should 
be  made  to  lie  as  much  as  possible  on  the  sound  side  for 
the  first  twenty-four  hours  to  prevent  blood,  etc.,  from 
accumulating  in  the  loose  cellular  tissue  at  the  axillary 
end  of  the  wound.  Of  course,  if  a  drainage-tube  has 
been  brought  out  through  the  skin  in  this  situation,  there 
will  not  be  the  same  necessity  for  this  position.  If  there 
is  much  pain  after  the  operation,  a  hypodermic  injection 
of  morphia  should  be  given  (|-  grain).  A  good  deal  of 
pain  is  not  uncommon  at  first  from  the  tension  of  the 
sutures,  especially  if  much  skin  has  been  removed. 

There  is  frequently  a  little  oozing  of  blood  through  the 
dressings  during  the  first  twenty-four  hours  ;  this  should 
be  looked  for  by  the  nurse  from  time  to  time,  and  when 
noticed,  more  wool  must  be  packed  on  over  the  part  of 
the  dressings  where  it  is  taking  place.  It  is  better  not 
to  redress  the  wound  unless  the  oozing  is  considerable. 
It  is  a  very  good  plan  for  the  first  two  or  three  days  to 
keep   large  pads  of  clean  wool  under  the  affected   side 

IS8 


Operations  on   the  Thorax         159 

between  the  dressings  and  the  bandages.  On  the  day 
following  the  operation  the  patient  should  be  propped  up 
into  the  half-sitting  position  with  a  bed-rest  and  pillows 
in  order  to  prevent  any  tendency  to  lung  complications. 

Lung  complications  are  very  liable  to  occur  after 
removal  of  the  breast,  especially  in  elderly  patients,  and 
as  carcinoma  is  a  disease  which  is  most  common  towards 
the  later  period  of  life,  many  of  the  patients  are  elderly. 
This  tendency  to  lung  complications  is  to  be  accounted 
for  by  the  limitation  of  the  thoracic  movements,  which 
must  of  necessity  result  from  the  presence  of  a  large 
wound  on  the  chest.  Any  deep  respiration  causes  pain, 
and,  as  a  result,  the  respirations  are  shallow  and  almost 
entirely  diaphragmatic  ;  respiration  is  also  impeded  by  the 
chest  being  tightly  bound  up  with  bandages,  etc.  It  is 
well  to  bear  this  in  mind,  as  otherwise  what  would  have 
been  a  successful  operation  may  result  in  the  death  of 
the  patient  from  an  intercurrent  bronchitis. 

If  a  tube  has  been  used  for  drainage,  it  should  be 
removed  on  the  first  or  second  day  after  the  operation 
and  the  wound  dressed ;  the  skin  at  the  axillary  end  of 
the  wound  should  be  carefully  cleaned  at  the  same  time. 

In  those  cases  where  a  large  amount  of  skin  has  been 
removed  and  the  axilla  freely  cleared  out,  the  arm 
should  be  fixed  after  the  operation  in  a  position  of 
abduction  from  the  trunk,  so  as  to  avoid  the  formation 
of  adhesions,  which  will  prevent  free  movement  of  the 
arm  after  the  wound  has  healed.  After  the  first  three 
or  four  days  the  arm  should  be  gently  moved  each  day  to 
prevent  the  formation  of  adhesions  between  the  skin  and 
deeper  structures.  These  movements  must  be  very  slight 
for  the  first  fortnight,  but  after  this  they  may  be  increased 
in  range  daily,  and  the  patient  encouraged  to  move  the 
arm  freely  herself.     A  certain   amount  of   limitation  of 


1 6c    The  After-Treatment  of  Operations 

movement  in  the  shoulder  on  the  affected  side  not  infre- 
quently results  after  this  operation  owing  to  the  extensive 
removal  of  skin,  which  is  often  necessary ;  but  much  can 
be  done  by  early  movements  to  overcome  this  tendency. 
Some  of  the  stitches  may  be  removed  at  the  end  of  the 
first  week,  and  the  remainder  at  the  end  of  a  fortnight. 
After  the  wound  has  healed  it  is  a  good  plan  to  have 
the  skin  gently  moved  on  the  deeper  tissues  each  day 
to  prevent  the  scar  from  becoming  adherent.  It  is 
hardly  necessary  to  mention  that  the  patient  should  be 
kept  under  close  observation  for  several  years  after  the 
operation,  so  that  should  recurrence  take  place,  it 
may  be  detected  and  dealt  with  at  the  earliest  possible 
date. 

When  an  extensive  area  of  skin  has  been  removed  with 
the  breast,  and  a  considerable  amount  of  tension  has  in 
consequence  been  necessary  to  bring  the  edges  together, 
sloughing  of  parts  of  the  skin-edges  may  result.  When 
this  is  seen  to  be  imminent,  the  tension  must  be  at  once 
relieved  by  dividing  the  sutures.  If  in  consequence  of 
sloughing  a  large  granulating  area  remains,  this  area 
should  be  covered  in  by  Thiersch's  skin-grafting,  so  as 
to  prevent  the  contraction  that  will  otherwise  result. 

Sepsis  after  removal  of  the  breast  is  a  very  serious 
complication,  owing  to  the  large  wound  and  the  extensive 
lymphatic  area  opened  up.  Septicaemia  is  very  liable  to 
follow,  and  may  prove  fatal.  Pleural  effusion  on  the 
same  side  as  the  wound  may  also  result,  and  become 
purulent. 

Operations  for  Empyema. 

Complications. — (i)  Non  -  expansion  of  the  lung  ; 
(2)  persistent  sinus ;  (3)  empyema  occurring  in  the  oppo- 


Operations  on  the  Thorax  i6i 

site  side  of  the  chest ;  (4)  cerebral  abscess  ;  (5)  curvature 
of  the  spine. 

After  the  operation  there  is  not  infrequently — and 
especially  is  this  the  case  with  children — a  good  deal  of 
respiratory  embarrassment  from  the  altered  conditions  of 
respiration  ;  slight  blueness  of  the  lips  may  often  be 
noticed,  and  is  evidence  of  insufficient  aeration  of  the 
blood  in  the  lungs.  This  is  best  met  by  oxygen  inhala- 
tion. The  patient  should  be  allowed  to  breathe  oxygen 
from  an  indiarubber-tube  attached  to  an  oxygen  cylinder 
whenever    the    breathing    seems    difficult    or    there   is 


Fig.  26. — Pollard's  Empyema  Tube. 
The  square  flange  should  go  inside  the  chest. 

cyanosis ;  this  helps  to  tide  over  the  period  until  the 
circulation  becomes  accustomed  to  the  new  respiratory 
conditions.  The  dressings  must  be  changed  frequently 
if  there  is  much  discharge,  and  the  same  care  should  be 
taken  as  in  deahng  with  a  sterile  wound,  as  it  is  most 
important  that  fresh  infection  should  not  be  engrafted  on 
to  that  already  present.  After  the  first  few  days  it  is 
usually  sufficient  to  change  the  dressings  once  daily.  It 
is  most  important  that  the  wound  in  the  chest  should  be 
kept  sufficiently  open  to  allow  of  free  drainage.  If  after 
the  fluid  has  drained  away  the  ribs  come  together  and 
narrow  the  opening,  there  should    be   no   hesitation    in 

IX 


1 62    The  After-Treatment  of  Operations 

enlarging  the  wound,  and,  if  necessary,  taking  away 
more  rib.  The  drainage-tube  should  be  removed  each 
day  and  cleaned  before  being  reinserted,  otherwise  it  is 
very  liable  to  become  blocked  by  pieces  of  pyogenic 
membrane,  etc. 

x\s  the  discharge  diminishes  in  amount  the  tube  may 
be  removed  and  a  smaller  one  substituted  for  it.  A  very 
good  tube  for  use  in  these  cases  is  Mr.  Bilton  Pollard's 
(see  Fig.  22).  It  is  easily  inserted,  and  has  the  advantage 
of  being  self-retaining.  It  is  best  to  keep  the  patient  in 
bed  for  the  first  week  or  ten  days,  and  then  if  his  condi- 
tion is  satisfactory  he  may  be  allowed  to  get  up  for  some 
part  of  the  day,  and  allowed  to  get  out  of  doors  for  a 
short  time  if  the  weather  is  favourable.  There  is  no 
fixed  time  for  which  the  tube  should  be  retained,  but,  as 
a  general  rule,  it  may  be  said  that  the  tube  should  be 
removed  as  soon  as  the  discharge  has  diminished  to  a 
drachm  or  two  of  clear  fluid.  After  the  tube  has  been 
left  out,  the  sinus  should  be  packed  with  gauze  daily  so 
as  to  insure  it  healing  from  the  bottom.  In  children  it 
is  often  possible  to  remove  the  tube  in  two  or  three  days 
after  the  operation.  When  the  dressing  is  changed,  the 
patient  should  be  turned  well  over  on  to  the  bad  side  so 
as  to  allow  any  pus  to  run  out,  and  the  patient  should  be 
instructed  to  cough.  This  will  often  help  to  get  rid  of 
any  pyogenic  membrane  or  pus  that  is  not  able  to  drain 
away.  Occasionally,  after  an  empyema  has  been  opened, 
there  are  still  symptoms  of  retained  pus,  such  as  high 
temperatures,  fever,  etc.,  even  though  free  drainage  has 
apparently  been  established.  This  is  generally  due  to 
the  empyema  being  loculated,  and  pus  still  remaining 
encysted  in  some  cavity  other  than  that  opened.  This 
pus  must  be  sought  for  and  evacuated.  The  best  way  of 
doing  this  is  to  push  a  large  catheter  in  different  direc- 


Operations  on  the  Thorax  16^ 

tions  until  the  pus  is  found,  or  the  finger  may  be  used  if 
the  external  opening  will  admit  of  it. 

Non-expansion  of  the  lung  after  operations  for  em- 
pyema is  a  very  serious  complication,  as  it  usually  leads 
to  deformity  of  the  chest  with  secondary  lateral  curvature 
of  the  spine,  and  results  in  a  persistent  discharging  sinus, 
which  is  a  continuous  source  of  trouble  and  inconvenience 
to  the  patient.  A  great  deal  can  be  done  to  assist  the 
lung  to  expand  by  sui:able  respiratory  exercises.  The 
exercises  that  are  suitable  for  hastening  and  facilitating 
expansion  of  the  lung  after  empyema  may,  with  advan- 
tage, be  divided  into  two  classes  : 

(i)  Those  suitable  while  there  is  still  an  opening  into 
the  pleural  cavity. 

(2)  Those  suitable  after  this  opening  has  closed.  (By 
an  opening  is  meant  one  which  establishes  a  condition  of 
pneumothorax,  and  not  a  sinus  shut  off  by  adhesions 
from  the  pleural  cavity.) 

In  (i)  we  have  to  deal  with  a  condition  of  pneumo- 
thorax, and,  consequently,  since  expansion  of  the  chest 
will  no  longer  give  rise  to  negative  pressure  in  the 
pleural  cavity  on  that  side,  we  cannot  avail  ourselves  of 
the  ordinary  breathing  exercises,  and  we  must  make  use 
of  the  positive  pressure  produced  by  the  sound  lung 
during  expiration  to  expand  the  affected  one.  The 
patient  should  be  made  to  expire  forcibly  against  resist- 
ance. The  simplest  way  of  doing  this  is  to  make  the 
patient  blow  forcibly  through  a  small  tube  held  in  the 
mouth,  such  as  a  piece  of  glass  tubing.  In  the  case  of  a 
child,  a  good  plan  is  to  give  it  a  whistle  or  trumpet  which 
will  not  make  a  noise  unless  blown  hard.  The  exercise 
may  be  modified  by  telling  the  patient  to  make  a  forcible 
expiratory  effort  with  the  glottis  closed,  and  then  to  let 
the   air   escape  slowly   through    the    partly  closed   lips. 


1 64    The  After-Treatment  of  Operations 


These  exercises  are  done  with  the  object  of  causing 
positive  pressure  in  the  affected  lung,  and  so  expanding 
it.     They  should  be  carried  out  regularly  from  the  first 

day,  and  gradually  increased 
from  day  to  day.  A  very 
simple  form  of  apparatus  for 
assisting  in  expansion  of  the 
lung  is  shown  in  Fig.  27.  It 
consists  of  a  large  quart  bottle 
with  a  wide  neck,  with  two 
glass  tubes  inserted  into  it, 
one  of  which  reaches  to  the 
bottom,  and  the  other  only  just 
through  the  cork.  To  the  longer 
tube  a  rubber  connection  is 
made  to  a  glass  mouthpiece. 
The  bottle  is  nearly  filled 
with  water,  and  the  patient 
is  instructed  to  blow  steadily 
through  the  tube  against  the 
Greater    resistance    can    be 


Fig.  27. 


resistance    of    the    water 
obtained  by  using  narrow  tubing. 

In  (2)  our  object  is  to  obtain  expansion  of  the  lung 
by  negative  pressure  in  the  pleural  cavity  as  in  normal 
respiration.  This  can  only  be  done  when  the  pleura  as 
a  cavity  is  closed  by  the  healing  of  the  wound  or  by  the 
formation  of  adhesions  between  the  visceral  and  parietal 
layers  of  the  pleura.  As  adhesions  are  almost  always 
present  to  some  extent,  these  exercises  can  usually  be 
commenced  before  the  wound  has  healed.  The  following 
exercises  are  taken  from  Dr.  H.  Campbell's  book  on 
respiratory  exercises  : 


operations  on  the  Thorax  165 

'  Breathing  Exercises  for  One  or  Both  Lungs. 

'  I.  Exercise  for  one  lung  only,  in  this  case  to  be  applied  to  the 
affected  lung. 

'  One  hand  is  ph.ced  in  the  axilla  of  the  sound  side  of  the  chest, 
and  pressed  firmly  against  the  chest  wall,  so  as  to  check  its  move- 
ments as  far  as  possible.  The  opposite  arm  is  then  raised  from  the 
side  until  the  wrist  rests  on  the  head.  While  the  movement  of  this 
arm  is  in  progress,  an  attempt  is  made  to  expand  to  the  utmost  the 
corresponding  side  of  the  thorax  at  the  same  time  that  the  body 
and  head  are  inclined  to  the  opposite  side. 

'  2.  Take  the  fullest  possible  thoracic  inspiration,  followed  by  an 
ordinary  expiration. 

'3.  Expire  to  the  utmost,  bending  the  body  somewhat  forward; 
then  take  an  ordinary  inspiration,  resuming  the  vertical  position. 

'  4.  Take  the  fullest  possible  thoracic  inspiration,  then  expire  to 
the  utmost,  bending  the  body  forward. 

'5.  The  patient  stands  erect,  and  then  blows  quickly  through  a 
small  opening  produced  by  pursing  the  lips.  At  the  same  time  he 
bends  the  head  and  then  the  dorsal  portion  of  the  spine,  whilst 
with  the  outspread  fingers  he  compresses  the  sides  of  the  thorax. 
Having  done  this,  the  fingers  are  enlaced  behind  the  neck,  the 
mouth  is  closed,  and  a  very  slow  and  prolonged  inspiration  taken 
through  the  nostrils,  whilst  at  the  same  time  the  spine  is  slowly 
extended. 

'  Breathing  Exercises  combined  with  Active  Exercises. — 6.  The  arms, 
held  stiff,  are  swung  round  as  far  as  possible  in  the  sagittal  direc- 
tion. Inspiration  accompanies  the  upward  movement,  expiration 
the  downward. 

'  7.  The  arms,  held  stiff,  are  moved  from  the  side  of  the  body 
outwards  in  a  lateral  plane  to  the  vertical,  and  then  returned  to  the 
original  position.  Inspiration  accompanies  the  upward  movement, 
expiration  the  downward. 

'  8.  The  arms,  held  horizontally  in  front  of  the  body  in  the 
sagittal  plane,  are  swung  backwards  in  the  horizontal  plane  as  far 
as  they  will  go,  and  then  returned  to  the  original  position.  In- 
spiration accompanies  the  former  movement,  expiration  the  latter. 

'  9.  The  arms  are  made  to  swing  in  the  lateral  plane  and  in  the 
same  direction,  so  as  to  reach  the  highest  possible  point  on  either 
side,  and  are  then  returned  to  the  original  position.  Inspiration  is 
taken  with  the  ascending  movement. 


1 66     The   After-Treatment  of  Operations 

'  Passive  Respiratory  Excixises. — lo.  The  operator  stands  behind  the 
patient's  head,  which  should  project  slightly  beyond  the  couch. 
The  upper  arms  are  then  grasped  by  the  assistant,  his  thumbs 
looking  upwards.  The  arms  are  then  brought  above  the  head,  so 
as  to  form  a  Ywith  the  body,  and  strong  traction  made  upon  them, 
the  patient  meanwhile  taking  a  deep  inspiration.  They  are  then 
brought  towards  the  thorax,  and  firmly  pressed  against  it,  while 
the  patient  takes  the  deep  expiration. 

'  II.  The  operator  stands  at  the  side  of  the  patient,  and  grasps 
the  arms  as  they  rest  at  each  side  of  the  body  just  above  the 
elbows,  his  thumbs  being  uppermost  and  looking  towards  the 
patient.  He  then  moves  the  limbs  in  a  horizontal  plane  until  the 
hands  meet  behind  the  head  of  the  patient,  who  meanwhile  takes  a 
deep  inspiration.  This  is  followed  by  a  deep  expiration  while  the 
limbs  are  moved  back  to  the  original  position,  the  elbows  being 
firmly  pressed  against  the  sides. 

'  12.  The  patient  lies  on  the  sound  side  of  the  chest,  with  the 
arms  above  the  head,  and  the  operator,  standing  behind,  places  the 
palm  of  each  hand  over  the  uppermost  part  of  the  thorax,  so  that 
the  roots  of  the  fingers  correspond  with  the  axillary  line.  The 
side  of  the  thorax  is  thus  grasped  between  the  fingers  and  thumbs. 
With  every  expiration  the  operator  makes  firm  pressure  on  the 
thorax,  and  endeavours  to  make  the  fingers  and  thumbs  meet.' 

Persistent  sinus  may  be  due  to  several  different  causes, 
one  of  which  will,  of  course,  be  non-expansion  of  the 
lung.  If  the  lung  has  expanded  properly,  and  yet  there 
is  persistent  septic  discharge  from  the  wound,  the 
presence  of  dead  bone  must  be  suspected  and  looked 
for  by  exploring  the  sinus  with  a  probe.  A  portion  of 
the  rib  is  often  found  to  be  necrosed,  the  necrosis  being 
most  commonly  along  the  lower  border  of  the  rib  above 
the  sinus.  When  this  is  the  case,  all  the  necrosed 
portions  of  rib  must  be  removed  before  the  sinus  will 
close.  Insufficient  drainage  from  the  chest  is  a  not 
mfrequent  cause  of  persistent  sinus,  and  when  the  dis- 
charge is  intermittent  from  the  sinus — that  is  to  say, 
when  the  wound  keeps  healing  up  and  breaking  down 
again  —  this   cause    must   especially    be   suspected;    the 


Operations  on   the  Thorax  167 

wound  under  these  circumstances  should  be  freely  opened, 
and  if  a  large  cavity  is  found  inside  the  chest,  it 
must  be  well  drained  until  it  has  almost  closed  up,  and 
then  made  to  heal  from  the  bottom  by  plugging.  Other 
and  rarer  causes  of  persistent  sinus  are  tubercular  disease 
of  the  pleura  ;  caries  of  the  spine,  to  which  the  empyema 
was  secondary  ;  and  the  development  of  calcareous  plates 
in  the  pleura. 

When  empyema  occurs  on  the  opposite  side,  it  is 
probably  safer  to  be  content  with  aspirating  the  chest  for 
a  few  days  to  allow  time  for  the  formation  of  adhesions, 
so  that  complete  collapse  of  the  lung  does  not  take  place 
when  the  chest  is  opened. 

With  regard  to  washing  out  the  pleural  cavity  after 
making  an  opening  into  the  chest,  this  procedure  has 
been  proved  to  be  dangerous,  however  carefully  practised. 
In  many  cases  no  harm  results,  but  in  a  few,  dangerous 
collapse  symptoms  and  even  sudden  death  have  followed 
after  the  most  careful  washing  out  of  the  cavity.  It 
is  therefore  safer  to  be  content,  as  a  rule,  with  simple 
drainage.  Should  it,  however,  be  thought  desirable  to 
irrigate  the  cavity,  as  is  sometimes  the  case  in  very  foul 
or  purulent  empyemata  that  resist  treatment  by  drainage 
alone,  the  patient  should  be  placed  in  the  recumbent 
position  while  this  is  being  done,  and  a  free  exit  must  be 
allowed  for  the  fluid  so  that  there  is  no  possibility  of  the 
irrigating  fluid  causing  tension  in  the  pleural  cavity 
while  the  irrigation  is  in  progress. 

The  constitutional  treatment  of  these  patients  is  of  the 
utmost  importance ;  fresh  air  and  an  early  change  to  the 
seaside  are  of  the  greatest  benefit  in  restoring  the  patient 
to  health.  Breathing  exercises  should  be  carried  out 
from  the  first  to  help  the  expansion  of  the  lung,  and 
later  on  proper  gymnastic  muscular  exercises  should  be 


1 68     The  After-Treatment  of  Operations 

enforced  to  prevent  the  tendency  to  contraction  of  the 
chest  and  curvature  of  the  spine.  This  is  particularly 
important  in  children  who  are  liable,  as  the  result  of 
empyema,  to  develop  marked  deformity  of  the  chest  and 
lateral  curvature  of  the  spine.  In  some  cases  curvature 
of  the  spine  after  empyema  may  be  looked  upon  as  a 
beneficial  condition  ;  that  is  to  say,  when  the  lung  has 
not  expanded  the  lateral  curvature  of  the  spine  allows 
the  chest  on  the  affected  side  to  fall  in  and  close  the  gap. 
When  the  deformity  is  very  marked,  however,  an  attempt 
should  always  be  made  to  get  rid  of  it  by  suitable  exer- 
cises, as  the  condition  is  apt  to  be  progressive. 


CHAPTER  XIII 

OPERATIONS  ON  THE  ABDOMEN :  GENERAL  TREAT 
MENT  AND  COMPLICATIONS 

The  After-Treatment  of  Laparotomy. 

A  GREAT  deal  depends  in  these  cases  on  the  way  in 
which  the  after  treatment  is  managed — more  so,  indeed, 
than  after  almost  any  other  class  of  case.  The  treat- 
ment, however,  must  be  carried  out  with  intelligence, 
and  must  be  based  upon  careful  observation  of  the 
individual  case,  as  these  cases  vary  very  much,  and 
hardly  two  of  them  are  quite  alike.  Anything  in  the 
way  of  routine  management  is  to  be  particularly  avoided, 
and  the  line  of  treatment  adopted  should,  so  far  as 
possible,  be  based  upon  physiological  facts,  the  medical 
attendant  trying  to  form  a  mental  picture  of  the  con- 
dition of  the  abdomen,  and  treating  the  case  accord- 
ingly. It  should  be  his  object  to  prevent  complications 
as  far  as  possible,  as  it  is  much  easier  to  prevent  the 
complications  that  are  liable  to  arise  than  to  treat  them 
after  they  have  once  become  well  established.  Meddle- 
some interference  must,  however,  be  avoided,  and 
especially  the  too  free  use  of  drugs.  When  complica- 
tions do  arise  the  treatment  must  be  vigorous,  as,  once 
well  established,  there  may  be  great  difficulty  in  com- 
bating them. 

r69 


170     The  After-Treatment  ot   Operations 

After  the  operation  the  patient  should  be  carried 
carefully  back  to  bed,  and  jolting  must  be  avoided,  as  it 
is  very  liable  to  increase  the  vomiting.  The  flannel 
gown  which  the  patient  has  worn  during  the  operation 
should  be  changed  for  a  clean  one,  which  has  been 
warmed,  and  hot-water  bottles  should  be  applied  to  the 
feet  and  elsewhere  if  necessary.  This  should  not  be 
overdone,  as  it  is  not  desirable  to  make  the  patient 
break  into  a  profuse  perspiration,  which  is  often  the  case 
if  the  use  of  hot-water  bottles,  etc.,  is  carried  to  excess. 
Care  must  be  taken  also  in  the  use  of  hot  bottles  not  to 
burn  the  patient.  Persons  who  are  under  the  influence 
of  an  anaesthetic  burn  extremely  easily,  and  it  is  not  at  all 
uncommon  to  see  quite  extensive  burns  from  this  cause 
in  hospital  practice. 

A  warm  nutrient  enema  should  be  administered  soon 
after  the  patient  has  been  got  back  to  bed,  and  it  is 
a  very  good  plan,  if  there  is  any  sign  of  shock,  to 
administer  an  enema  of  warm  water  i  pint  and  brandy 
I  ounce.  This  may  either  be  combined  with  a  nutrient 
enema,  or  given  separately.  Mr.  Watson  Cheyne  advises 
an  enema  containing  hot  coffee  (2  ounces),  brandy 
(i  ounce),  beef-tea  (i  ounce),  and  liquor  strycbninae 
(10  minims). 

If  there  is  vomiting,  and  it  does  not  stop  in  a  short 
time,  hot  flannels  may  be  applied  to  the  epigastric 
region,  and  the  patient  can  be  allowed  to  drink  some  hot 
water  with  some  bicarbonate  of  soda  dissolved  in  it  ($ee 
under  Post-Anaesthetic  Complications). 

In  cases  where  there  is  constant  regurgitation  of  fluid 
from  the  mouth  rather  than  actual  vomiting,  as  is  not 
uncommonly  seen  in  cases  of  intestinal  obstruction  and 
peritonitis,  this  can  often  be  stopped  by  just  propping 
the  patient    up  a  little  so  as  to  allow   gravity  to   act. 


Operations  on  the  Abdomen        171 

This  is  not  advisable,  however,  when  there  is  shock 
present.  A  better  method  of  preventing  this  type  of 
regurgitant  vomiting  is  by  washing  out  the  stomach.  This 
should  be  done  before  the  patient  leaves  the  operating 
table.  If  there  is  much  pain  after  the  patient  regains 
consciousness,  it  may  sometimes  be  relieved  by  flexing 
the  patient's  knees  over  a  pillow,  so  as  to  relax  the 
abdominal  muscles.  A  saline  enema  containing  10  to  15 
grains  of  aspirin  administered  directly  after  the  operation 
will  often  relieve  pain  and  avoid  the  necessity  of  giving 
morphia.  If  very  severe,  an  injection  of  morphia  must 
be  given,  but  it  is  as  well  to  avoid  the  use  of  opium  if 
possible,  as  it  increases  the  liability  to  meteorism.  If 
there  is  much  restlessness,  morphia  is  indicated.  It 
should  be  given  in  a  dose  of  from  ^  to  ^  grain  hypo- 
dermically,  according  to  circumstances.  Heroin  (J^  to 
TS  S^^^^)  "^3-y  be  used  instead  of  morphia  with  advan- 
tage. With  regard  to  position,  the  patient  should,  as  a 
rule,  be  allowed  to  lie  in  the  most  comfortable  position, 
and  this  will  usually  be  found  to  be  upon  the  side  (see 
Introductory  Chapter). 

Relief  of  Distension. — In  order  to  prevent  the  pos- 
sibility of  meteorism,  an  excellent  plan  is  to  pass  a  small 
tube,  such  as  the  ivory  nozzle  of  an  ordinary  Higginson's 
syringe,  through  the  sphincters  twice  in  the  twenty-four 
hours,  and  leave  it  in  for  one  hour  at  a  time.  It  does  not 
cause  the  least  discomfort,  and  allows  of  the  escape  of 
flatus.  When  the  patient  is  elderly  it  is  always  advisable 
to  pass  a  catheter  once  a  day  for  the  first  few  days  to 
make  certain  that  the  bladder  is  being  properly  emptied. 
On  the  second  or  third  day  after  the  operation,  and 
earlier  if  the  patient's  bowels  have  not  been  well  opened 
previous  to  the  operation,  a  soap-and-water  enema  should 
be  administered,  and  repeated  in  an  hour  if  there  is  no 


ij2     The  After-Treatment  of  Operations 

action  of  the  bowels.  If  this  fails  to  act,  an  oil  enema 
may  be  given,  or  a  dose  of  castor-oil  (i  ounce)  given  by 
the  mouth,  or  calomel,  \  grain  every  hour  for  eight  hours, 
or  until  the  bowels  act,  may  be  used  instead  of  the  oil,  or 
salts  in  repeated  doses  every  two  hours  are  preferred  by 
some  surgeons.  In  cases  where  there  is  uncomfortable 
distension  of  the  abdomen  after  laparotomy  the  author 
adopts  the  following  procedure :  A  turpentine  enema, 
consisting  of  turpentine  gss.  and  thin  gruel  14  ounces,  is 
first  given  ;  if  this  fails  to  give  relief,  a  hypodermic  injec- 
tion of  I  c.c.  of  pituitary  extract  is  given,  followed  at 
once  by  an  enema  consisting  of  fels  bovinum,  i  drachm 
in  i^  pints  of  water.  This  results  in  immediate  and  com- 
plete relief  of  the  distension  in  most  cases.  Eserine 
may  also  be  used  hypodermically  for  the  same  purpose. 
This  question  of  aperients  is  a  very  important  one,  and 
surgeons  differ  very  much  as  to  the  exact  procedure;  but 
it  may  be  stated  as  a  general  principle  that  the  sooner  a 
proper  evacuation  of  the  bowels  has  been  obtained,  the 
sooner  is  the  patient  out  of  danger.  The  importance  of 
getting  the  bowels  to  act  early  after  abdominal  operations 
is  well  shown  by  the  following  figures,  for  which  I  am 
indebted  to  Dr.  Darwall  Smith,  who  has  investigated  this 
subject  in  an  analysis  of  42  consecutive  cases  of  abdominal 
section. 

Of  these  42  cases,  13  developed  complications  in  the 
form  of  vomiting  or  distension,  or  both. 

In  II  cases  the  bowels  were  opened  by  aperients  or 
enemata  on  the  second  or  third  day,  and  of  these  2 
developed  complications. 

In  20  cases  the  bowels  were  similarly  opened  on  the 
fourth  or  fifth  day,  and  of  these  5  developed  complications. 

In  II  cases  the  bowels  were  left  to  nature,  and  of  these 
6  developed  complications. 


Operations  on    the  Abdomen        173 

The  generally  accepted  view  among  surgeons  now  is 
that  meteorism  or  paralytic  distension  is  due  to  sepsis ; 
in  other  words,  is  a  mild  form  of  peritonitis.  At  any  rate, 
it  does  not  occur  if  strict  aseptic  conditions  are  secured, 
and  the  interior  of  the  abdomen  is  not  handled  roughly. 
This  complication  should  not  occur  now  as  the  result  of 
laparotomies,  unless  there  are  septic  lesions. 

Our  object  must  be  to  get,  if  possible,  a  natural  action, 
unaccompanied  by  violent  peristalsis.  The  best  way  of 
doing  this  is  by  the  use  of  enemata,  which  are  probably 
the  least  irritating  form  of  aperient  and  at  the  same 
time  produce  their  effect  with  the  least  amount  of  peri- 
stalsis. With  regard  to  the  use  of  aperient  drugs, 
salts,  especially  in  small  repeated  doses,  are  probably 
the  least  irritating  to  the  intestine,  and  take  effect 
without  giving  rise  to  much  muscular  action  of  the 
intestinal  wall  ;  but,  unfortunately,  they  are  very  liable 
in  some  cases  to  cause  vomiting,  which  it  is  often  par- 
ticularly desirable  to  avoid.  One  of  the  best  ways  of 
administering  salts  for  the  evacuation  of  the  bowels  in 
these  cases  is  in  small  doses  dissolved  in  a  large  quantity 
of  water,  as,  for  instance — 

'^    Mag.  sulph.  .  „  .  .  5ss.-i. 

Sodse  sulph.  .  _  .  .  5ss.-i. 

Aquam        -  -  -  -  -  ad  gvi. 

Sig.  :    Every  hour  till  the  bowels  act. 

The  value  of  saline  purgation  in  the  treatment  of 
insipient  peritonitis  has  been  repeatedly  proved,  and 
there  can  be  no  doubt  of  its  usefulness  in  appropriate 
cases.  The  late  Mr.  Lawson  Tait  was  one  of  the  first 
surgeons  to  revive  the  practice,  and  he  used  to  speak 
very  highly  of  the  value  of  saline  purgation  in  the  after- 
treatment  of  ovariotomy  cases. 


174    The  After-Treatment  of  Operations 

It  has  recently  been  pointed  out  by  McCullum  that 
most  of  the  saline  aperients  act  even  more  readily  if 
administered  hypodermically  than  if  given  by  the  mouth. 
This  method  of  administration  may  be  tried  in  cases 
where  salts  cause  vomiting  when  given  in  the  ordinary 
way. 

Castor  oil  is  certainly  one  of  the  most  reliable  and 
most  valuable  aperient  drugs  that  we  possess,  and, 
when  it  can  be  taken,  is  in  many  cases  preferable  to 
the  use  of  salts.  An  ounce  of  the  oil  may  be  given 
on  the  morning  of  the  third  day  after  the  operation. 
Calomel,  especially  in  small  repeated  doses,  is  very 
useful  in  some  cases,  and  should  be  made  use  of  in 
preference  to  salts  or  oil  in  cases  where  there  is  peri 
tonitis  present  or  suspected  ;  but  as  calomel  acts  largely 
by  virtue  of  its  irritating  qualities,  causing  peristalsis, 
it  must  be  used  with  caution.  Great  judgment  and 
care  is  necessary  in  the  employment  of  aperients  after 
laparotomy,  and  careful  observation  of  cases  combined 
with  a  knowledge  of  the  physiology  of  the  intestine 
will  be  of  more  service  in  the  treatment  of  cases  than 
any  amount  of  reading. 

One  warning  must,  however,  be  given.  In  the  aged 
and  in  weakly  subjects,  too  active  purgation,  especially 
by  irritant  drugs,  like  calomel,  etc.,  should  be  avoided,  as 
it  is  liable  to  set  up  an  intractable  diarrhoea  which  may 
prove  fatal  from  exhaustion.  After  the  bowels  have 
been  opened  a  mild  aperient  should  be  given  daily  so  as 
to  insure  a  sufficient  daily  action.  For  this  purpose  a 
teaspoonful  of  liquid  cascara  or  liquorice  powder  is  as 
good  as  anything. 

Treatment  of  the  Wound. — When  the  abdominal 
wall  has  been  sewn  up  in  layers,  the  superficial  stitches 
should  be  removed  in  a  week,  the  deep  ones,  of  cotirse, 


Operations  on  the  Abdomen        175 

being  left.  After  the  stitches  have  been  removed,  the 
wound  should  be  supported  with  broad  pieces  of  strap- 
ping so  as  to  prevent  any  strain  being  thrown  upon 
the  newly-united  wound  edges,  and  a  firm  flannel  binder 
should  be  worn  over  this. 

If  the  abdominal  wall  has  been  sewn  up  with  non- 
absorbable stitches  passing  through  all  the  layers  of  the 
abdominal  wall,  the  stitches  should  be  left  in  for  ten 
days.  If  a  drainage-tube  has  been  inserted  into  the 
wound,  it  should  be  removed  in  twenty-four  hours  unless 
there  is  pus  draining  away,  in  which  case  it  should  be 
retained.  Drainage  of  the  abdominal  cavity  is  not  effi- 
cient after  twenty-four  hours,  as  the  tube  is  shut  off  by 
adhesions. 

The  period  of  recumbency  necessary  after  laparotomy 
depends  on  several  factors.  The  way  in  which  the 
incision  has  been  made  and  closed,  the  size  of  the  incision, 
and  the  condition  of  the  abdominal  wall,  have  to  be 
considered.  In  the  case  of  a  short  incision  made  through 
the  rectus  sheath  or  by  separating  the  muscles  and  sub- 
sequently closed-in  layers,  there  is  no  risk  of  hernia ;  the 
patient  may  be  got  up  as  soon  as  the  wound  has  firmly 
healed,  which  will  be  in  about  ten  days,  and  a  belt  is 
quite  unnecessary. 

In  cases  where  the  wound  is  large,  and  has  not  been 
made  by  splitting  muscles,  it  is  advisable  to  keep  the 
patient  in  bed  for  a  period  of  three  weeks  before  allowing 
him  to  assume  the  erect  position.  It  is  better  to  err  on 
the  side  of  keeping  the  patient  recumbent  a  little  too 
long  than  to  run  the  risk  of  a  hernia. 

In  the  case  of  women  it  is  generally  advisable  to  fit 
a  belt,  which  should  be  worn  for  some  months  after 
the  operation.  This  is  not  so  much  to  prevent  the 
formation  of  a  hernia  as  to  enable  the  patient  to  get 


176     The  After-Treatment  of  Operations 

about  without  becoming  exhausted  In  many  women 
the  abdominal  muscles  are  rather  poorly  developed,  and 
as  a  result  of  the  operation  or  the  consequent  rest  in  bed, 
they  are  often  very  weak  for  some  time  after.  A  properly 
fitting  belt  will  do  much  to  diminish  this  feeling  of 
weakness,  and  will  be  found  of  great  advantage. 

No  active  exercise  or  any  exertion,  such  as  lifting 
heavy  weights,  should  be  indulged  in  for  at  least  two 
months  after  the  operation. 

Diet. — This  is  one  of  the  most  important  parts  of  the 
after-treatment  of  abdominal  cases,  and  we  must  be 
guided  largely  by  the  nature  of  the  case  in  the  selection 
of  a  suitable  diet.  When  there  is  a  lesion  in  any  portion 
of  the  alimentary  tract,  our  object  must  be  to  avoid  the 
use  of  any  diet  which  will  need  digestion  or  necessitate 
peristalsis  by  that  portion  of  the  intestine.  Thus,  in 
stomach  cases  we  should  avoid  the  use  of  foods  which 
are  normally  digested  by  that  organ,  and  in  the  case  of 
lesions  of  the  small  intestine  w^e  should  make  use  of  foods 
which  can,  to  a  large  extent,  be  digested  by  the  stomach, 
and  so  on.  One  thing  must  especially  be  avoided — that 
is,  the  use  of  any  diet  which,  in  the  process  of  digestion 
or  otherwise,  is  liable  to  cause  the  formation  of  gas,  and 
so  flatulence  and  distension. 

At  the  time  when  the  first  edition  of  this  book  appeared 
it  was  the  practice  to  put  all  laparotomy  patients  upon 
special  "  slop "  diets ;  considerable  importance  was 
attached  to  the  particular  kind  of  diet,  and  much  care 
was  taken  in  the  preparation  of  diet  sheets.  Any  com- 
plications which  arose  were  frequently  ascribed  to  the 
patient's  being  allowed  solid  diet  too  soon.  Surgeons 
have  now,  for  the  most  part,  come  to  hold  a  view  which 
is  more  in  accordance  with  common  sense,  and  only  with- 
hold those  articles  of  diet   which  they   believe  may  do 


Operations  on   the  Abdomen        177 

harm.  The  author  has  for  some  years  given  up  the  use 
of  so-called  "slop"  diets,  except  in  special  cases.  His 
practice  is  to  allow  no  food  until  the  anaesthetic  sickness 
has  stopped,  and  then  to  give  the  patient  in  moderate 
quantity  an  ordinary  diet  such  as  he  has  been  accus- 
tomed to.  Thus,  if  there  has  been  no  sickness  during  the 
night  after  operation,  the  patient  is  allowed  a  light  break- 
fast consisting  of  a  little  bacon,  a  lightly  boiled  egg,  and 
bread  and  butter ;  and  for  luncheon  chicken  or  fish, 
followed  by  a  milk  pudding  or  a  little  stewed  fruit  and 
custard. 

The  author  argues  that  after  an  operation  on  the 
abdomen,  or  indeed  after  any  operation,  it  is  most  desir- 
able that  the  patient  should  not  have  indigestion  or 
flatulence  added  to  his  other  discomfort,  and  that  to  put 
a  man  or  woman  who  has  for  years  been  living  on  an 
ordinary  diet  on  to  a  "  slop  "  diet  is  a  certain  way  of 
producing  indigestion.  Anyone  who  doubts  this  has  only 
to  put  himself  on  a  "  slop  "  diet  for  a  couple  of  days  to 
prove  it.  He  will  find  that  he  is  suffering  from  flatulence 
and.  indigestion  within  a  \'ery  short  time.  The  author 
has  found  that  since  adopting  his  present  method  of 
dieting  patients  after  laparotomy,  discomfort  from  wind 
and  flatulence  has  practically  disappeared  altogether,  and 
with  this  many  other  troubles  that  used  to  be  all  too 
common,  such  as  insomnia,  heartburn,  and  loss  of 
appetite.  The  above  remarks  do  not,  of  course,  apply  to 
patients  who  previous  to  the  operation  were  on  a  special 
diet,  as  the  object  should  be  to  avoid  an  alteration  of  the 
patient's  diet.  When,  too,  the  alimentary  canal  has  been 
seriously  interfered  with,  as  in  the  case  of  anastomosis, 
etc.,  some  modification  and  restriction  of  diet  is  advisable, 
though  not  to  the  extent  often  supposed.  One  must 
always  remember  that  it  is  not  the  condition  (of  solidity, 


178     The  After-Treatment  of  Operations 

etc.)  of  the  food  when  eaten  that  is  important,  but  its  con- 
dition during  and  after  digestion.  Ease  of  digestion  is 
important,  but  it  should  be  obvious  that  the  most  readily 
digested  diet  is  that  to  which  the  individual  is  accus- 
tomed. 

When  a  very  severe  opcrat'on  has  been  performed, 
such  as  one  involving  surgical  shock,  or,  more  particularly, 
one  for  the  relief  of  peritonitis  or  some  serious  inflam- 
matory condition  of  the  abdomen,  the  case  is  different, 
and  special  diet  is  advisable  until  normal  conditions  are 
re-established. 

It  must  be  remembered  that  the  alimentary  tract  under 
these  circumstances  is  not  in  a  normal  condition,  that 
digestion  is  often  not  complete,  and  fermentation  and 
other  abnormal  processes  are  very  liable  to  take  place. 
Milk,  which  is  a  very  commonly  used  diet  in  these  cases, 
is  particularly  unfortunate  in  this  respect,  as  it  is  very 
liable  not  to  be  properly  digested  and  to  undergo  fer- 
mentation, and  give  rise  to  the  formation  of  gas,  etc.  It 
is  probably  one  of  the  worst  forms  of  dietary  in  many 
of  these  cases  ;  and  although  peptonizing  it  does  a\\  ay 
to  some  extent  with  this  disadvantage,  it  does  not  do  bo 
altogether,  as  it  is  even  then  liable  to  undergo  fermenta- 
tion in  the  stomach  and  intestines,  and,  in  addition,  the 
peptones  used  to  peptonize  it  are  irritating.  One  of  the 
safest  and  most  reliable  diets  is  albumin-water.  This  is 
made  by  beating  up  the  white  of  three. or  four  eggs  in 
a  pint  of  water,  lemon  and  sugar  or  other  flavouring 
materials  being  added  according  to  taste.  This  is  very 
easily  digested,  is  unirritating,  and  at  the  same  time  is 
not  liable  to  give  rise  to  the  formation  of  gas  during  the 
process  of  digestion  ;  2  pints  of  albumin-water  given 
during  the  twenty-four  hours  represents  a  fair  amount  of 


Operations  on   the  Abdomen        179 

nutritive  material,  and,  as  a  rule,  is  all  that  is  necessary 
during  the  first  two  or  three  days.  About  2  ounces 
should  be  given  by  the  mouth  every  two  or  three  hours 
while  the  patient  is  awake.  If  desired,  the  albumin- 
water  may  be  combined  with  peptonized  milk,  but  it  is 
better  to  avoid  the  use  of  milk  altogether  till  after  the 
bowels  have  acted.  Another  preparation  which  may  be 
used,  and  which  is  very  similar  to  the  albumin-water,  is 
plasmon. 

Plasmon*  is  a  pure  albumin  prepared  from  the 
caseinogen  of  milk.  It  is  a  fine  white  granular  powder, 
which  is  readily  soluble  and  free  from  taste  or  smell.  It 
can  be  added  to  almost  any  form  of  diet,  and,  as  it  con- 
tains a  very  high  percentage  of  albumin,  forms  a  very 
useful  method  of  administering  proteid.  It  has  the 
advantage  of  being  the  cheapest  form  of  pure  albumin 
obtainable,  as  it  is  prepared  from  butter-milk,  a  by- 
product in  the  preparation  of  butter.  It  is  a  very 
easily  assimilated  form  of  albumin,  and,  owing  to  its 
method  of  manufacture,  is  free  from  chemicals.  In 
abdominal  cases  it  is  best  given  either  as  a  beverage 
or  as  jelly  : 

Plasmon  -  -  -  -     3  teaspoonfuls. 

Tepid  water      -  -  -  -     ^  pint 

A  little  water  should  be  added  to  the  plasmon,  and 
then  stirred  into  a  thick  paste ;  the  remainder  of  the 
water  should  then  be  added,  and  the  whole  boiled  for 
two  minutes.  This  will  give  |  pint  of  the  liquid.  About 
2  ounces  of  this  should  be  given  to  the  patient  every 
two  or  three  hours,  with  more  water  and  some  suitable 
flavouring  added  according  to  taste.      As  a  change  the 

*  There  are  now  many  substitutes  for  Plasmon,  such  as  ovaltine^ 
aanatogen,  etc. 


i8o     The  After-Treatment  of  Operations 

plasmon  may  be  given  as  jelly  or  cocoa,  and  later,  when 
solid  foods  are  begun,  it  is  a  very  good  plan  to  combine  a 
certain  amount  of  plasmon  each  day  with  the  diet.  The 
amount  of  plasmon  which  it  is  advisable  to  give  in  the 
twenty-four  hours  must,  of  course,  vary  a  good  deal  with 
circumstances,  but  roughly  it  should  be  from  three  to 
six  teaspoonfuls  of  the  powder. 

A  very  useful  diet  for  many  of  these  cases,  which  was 
first  drawn  attention  to  by  Mr.  H.  Gilford  [British  Medical 
Journal,  November  i6,  1901),  is  grape-sugar.  To  quote 
his  own  words  : 

'  In  my  opinion  one  of  the  best  of  these  foods  is  grape- 
sugar.  Grape-sugar  by  itself  is  too  nauseous,  but  com- 
bined with  a  flavour,  such  as  that  of  raisins,  it  is  nearly 
always  palatable.  I  find,  in  fact,  that  it  is,  as  a  rule, 
preferred  to  nearly  all  other  forms  of  liquid  diet,  and 
patients  will  often  by  preference  continue  taking  their 
"raisin-tea"  long  after  they  have  become  tired  of  milk 
and  slops.  It  is  made  by  pouring  boiling  water  on  to 
half  its  bulk  of  chopped  raisins.  This  is  stewed  for  about 
two  hours  and  then  filtered.  The  filtrate  may  be  given 
either  with  water  or  without,  and  either  hot  or  cold, 
according  to  the  wishes  of  the  patient.  Though  it  doubt- 
less contains  other  substances  than  grape-sugar,  these 
are  apparently  present  in  such  small  quantities  that  they 
may  be  neglected.  Given  at  first  in  small  doses  and 
afterwards  more  freely,  it  is  undoubtedly  of  value.  When 
one  remembers  the  important  place  which  sugar  takes 
among  the  foods,  it  seems  strange  that  it  should  not  be 
more  utilized  as  an  article  of  sick  diet.  This  applies  with 
peculiar  force  to  grape-sugar,  seeing  that  it  requires  no 
digestion.' 

A  combination  of  egg-albumin  or  plasmon  with  grape- 
sugar  in  the  form  of  '  raisin-tea  '  is  a  most  excellent  diet 


Operations  on   the  Abdomen        i8i 

for  these  cases  during  the  first  few  days.  It  combines 
a  maximum  of  nutrition  in  an  easily  assimilated  form 
with  a  minimum  of  bulk  and  residue  ;  it  contains  both 
proteid  and  carbohydrate  —  the  former  in  an  easily 
digested  form,  and  the  latter  in  a  form  which  requires  no 
digestion  at  all. 

Beef-tea,  which  is  still  so  popular  as  a  form  of  invalids' 
diet,  is  practically  useless  except  as  a  stimulant,  and 
there  are  many  better  stimulants  than  beef-tea.  A  recent 
chemical  analysis  made  of  the  beef-tea  in  one  of  the  big 
hospitals  revealed  the  fact  that  the  best  beef-tea  only 
contained  3*4  per  cent,  of  proteid,  so  that  beef-tea  and 
the  numerous  other  beef  extracts  are  quite  useless  as  a 
diet.  A  recent  writer  on  the  subject  says:  'AH  the 
bloodshed  caused  by  the  warlike  ambition  of  Napoleon 
is  as  nothing  compared  to  the  myriads  of  persons  who 
have  sunk  into  their  graves  from  a  misplaced  confidence 
in  the  food  value  of  beef-tea.' 

When  stimulants  are  necessary  or  advisable,  brandy 
and  whisky  are  the  best,  and  it  is  better  to  give  them  in 
small  repeated  doses  either  separately  or  combined  with 
the  fluid  diet  than  to  give  them  in  large  doses.  Cham- 
pagne is  sometimes  valuable,  but,  as  a  rule,  it  is  better 
to  avoid  the  use  of  gaseous  drinks,  as  they  often  cause 
flatulence. 

For  the  first  four  or  five  hours  after  the  operation  it  is 
advisable  not  to  give  anything  by  the  mouth  except 
water.  If  the  patient  is  thirsty,  some  lemon-juice  may 
be  added  to  the  water  with  advantage,  or  peppermint- 
water  is  sOiTietimes  very  comforting.  About  a  tea-cupful 
of  fluid  should  be  allowed  at  a  time.  There  is  no  advan- 
tage in  only  giving  the  fluid  in  small  sips  ;  such  small 
quantities  of  water  are  just  as  liable  as  larger  quantities 
to  cause  vomiting,  and  the  latter  will  have  the  advantage 


182     The  After-Treat m en t  of  Operations 

of  laving  the  stomach  if  it  is  vomited.  It  is  correct  in 
these  cases  to  assume  that  thirst  is  the  physiological  call 
of  the  body  for  more  fluid,  and  therefore  it  ought  to  be 
satisfied  as  far  as  possible.  Large  quantities  of  fluid  at 
a  time  are,  however,  not  advisable,  as  they  are  liable  to 
cause  vomiting  by  distending  the  stomach  ;  but  giving 
water  only  in  teaspoonfuls  is  neither  reasonable  nor  does 
it  answer  any  real  purpose.  A  cup  of  tea  with  a  little 
sugar  but  no  milk  is  often  very  much  appreciated  when 
the  vomiting  has  passed  off.  It  should  be  made  weak, 
and  must  not  be  allowed  to  stand  before  being  drunk. 

Complications  of  Laparotomy. — (i)  Shock ;  (2) 
vomiting;  (3)  meteorism  ;  (4)  peritonitis  ;  (5)  stitch  sup- 
puration ;  (6)  faecal  fistula;  (7)  parotitis;  (8)  weak  scar  ; 
(9)  intestinal  obstruction;  (10)  adhesions;  (11)  ventral 
hernia;  (12)  acute  dilatation  of  the  stomach. 

1.  Shock. — This  condition  has  already  been  treated  of  in 
a  separate  chapter,  and  will  not  be  further  considered  here. 

2.  Vomiting. — This  has  also  been  considered,  but  it 
may  be  mentioned  here  that  in  very  bad  cases  of  per- 
sistent vomiting,  which  will  not  yield  to  the  ordinary 
treatment,  washing  out  the  stomach  with  warm  water 
should  be  tried  and  repeated  at  intervals  of  two  or  three 
hours  if  necessary.  Propping  the  patient  up  into  a 
semi-sitting  position  is  also  sometimes  of  use.  It  should 
be  our  object  to  remove  the  cause  of  vomiting  rather 
than  to  check  it  (see  p.  98). 

3.  Meteorism. — This  is  the  most  dangerous  complication 
that  is  commonly  met  with  after  laparotomy.  A  good 
deal  has  been  written  on  this  subject  under  the  name 
of  'pseudo-ileus,'  a  new  name  which  seems  to  have 
little  to  recommend  it.  Tympanites  is  also  another  name 
which  has  been  used  to  describe  this  condition.  What- 
ever the  exact  physiological  cause  of  the  condition  may 


Operations  on   the  Abdomen        183 

bs,  whether  it  is  due  to  paralysis  of  the  intestinal  muscu- 
lature or  to  some  other  cause,  it  is  a  condition  which  is 
not  uncommonly  seen,  and  when  once  well  established, 
it  is  often  extremely  difficult  to  treat.  It  usually  first 
shows  itself  about  twenty-four  to  forty  eight  hours  after 
the  operation  by  distension  of  the  abdomen  accompanied 
by  some  discomfort.     The  patient's  breath  is  often  foul. 

In  the  fatal  cases  this  distension  steadily  increases, 
and  is  accompanied  by  constipation,  which  may  become 
absolute,  the  patient  dying  either  from  a  kind  of  toxaemia, 
due,  no  doubt,  to  the  absorption  of  poisons  from  the 
intestine,  or,  in  some  cases,  from  a  variety  of  peritonitis. 
A  certain  amount  of  flatulence  after  laparotomy  is  quite 
common,  especially  when  the  operation  has  been  under- 
taken for  the  relief  of  some  septic  condition,  as,  for 
instance,  in  the  case  of  appendicitis. 

The  modern  view  of  post-operative  meteorism  is  that 
it  is  due  to  sepsis  and  peritonitis,  and  that  consequently 
the  best  way  of  preventing  it  is  care  in  operating  as 
regards  careful  aseptic  technique,  and  especially  the 
avoidance  of  rough  and  unnecessary  handling  of  the 
ab-Iominal  contents. 

Our  object  must  be  to  prevent  the  onset  of  this  trouble- 
some complication  by  appropriate  means.  The  method 
of  passing  a  tube  through  the  sphincters  and  leaving  it 
there  is  certainly  one  of  the  best  means  of  securing  this 
end.  The  late  Mr.  Herbert  AUingham  pointed  out  that 
it  is  necessary,  for  the  expulsion  of  flatus,  that  the 
abdominal  muscles  should  contract,  and  that  after  a 
wound  has  been  made  in  the  abdominal  wall  the  patient 
is  unable,  or  unwilling,  to  contract  these  muscles,  on 
account  of  the  pain  which  it  causes  him,  and  in  conse- 
quence flatus  tends  to  accumulate  in  the  intestines. 
Wherj  the  tube  is  in  position^  however^  there  is  a  fre§ 


1 84    The   After-Treatment  of  Operations 

way  through  the  sphincters,  and  wind  is    able    to   pass, 
unaided. 

As  soon  as  distension  has  made  its  appearance,  steps 
must  at  once  be  taken  for  its  relief.  An  enema  should 
be  administered,  and  probably  one  of  the  best  enemas 
for  the  purpose  is  a  turpentine  one,  such  as  that  in  the 
old  British  Pharmacopoeia: 

^     Turpentine  -  -  -  -       Bi- 

Gruel        -  -  -  .  -      §xvL 

or  a  rue  enema  may  be  used,  as : 

fi     Confectionis  rutse  -  -  -      5i"- 

Infusum  anthemidis         -  -  -       ad  5xvi.* 

After  the  enema  has  been  given,  the  rectal  tube 
should  be  passed  through  the  sphincters  and  left  there 
for  an  hour,  so  as  to  allow  of  the  escape  of  wind.  It  is 
a  good  plan  to  let  the  tube  be  kept  in  for  one  hour  out 
of  every  six  when  there  is  any  distension.  An  excellent 
plan  which  the  author  has  used  for  some  years  and 
has  hardly  ever  known  to  fail  in  giving  instant  relief  is 
as  follows  :  If  the  first  enema  fails  to  relieve  the  dis- 
tension, a  second  is  given,  either  of  turpentine  or,  better 
still,  of  fels  bovinum  (B.P.),  2  drachms  to  warm  water, 
2  pints,  and  immediately  after  the  enema  a  hypodermic 
mjection  of  pituitary  extract,  i  c.c.  This  usually  results 
in  a  free  passage  of  flatus,  and  may  be  repeated  if  the 
distension  shows  signs  of  returning  in  a  few  hours.  If 
these  measures  do  not  prove  effectual  in  relieving 
the  distension,  large  oil  enem.ata  should  be  used,  or 
castor  oil,  calomel,  or  salts  given  in  repeated  doses  by 
the  mouth  until  the  bowels  are  open. 

As  a  rule,  the  condition  will  yield  to  the  above  treat- 

*  St.  George's  Hospital  Pharmacopoeia. 


Operations  on   the  Abdomen        185 

ment  if  it  is  commenced  early  and  carried  out  vigorously. 
In  very  bad  cases  powerful  enemata,  containing  large 
doses  of  glycerine,  or  glycerine  and  magnesium  sulphate, 
are  sometimes  successful: 

^     Glycerini  .  ..  -  .      §i.-i.ss. 

Mag.  sulph.         ....      gss. 
Aquam      -  .  .  .  .      gvi. 

Recently  subcutaneous  injections  of  physostigmin 
have  been  used  to  stimulate  peristalsis  in  these  cases, 
and  good  results  are  claimed  for  this  method  of  treat- 
ment. The  dose  is  -^3-^-  grain,  and  the  injection  should 
be  followed  in  half  an  hour  by  a  glycerine  enema.  The 
injection  may  be  repeated  in  six  hours  if  unsuccessful. 
With  the  same  object  the  author  has  used  hypodermic 
injections  of  pituitary  extract,  I  c.c,  with  very  good 
results. 

Lastly,  in  very  bad  cases  the  advisability  of  re- 
opening the  abdomen  and  incising  the  bowel  may  be 
considered. 

4.  Peritonitis. — The  question  of  reopening  the  abdomen 
will  have  to  be  considered.  If  this  is  not  done,  our  only 
hope  is  in  getting  the  bowels  to  act.  Calomel  in  re- 
peated doses  is  probably  the  best  way  of  securing  this  in 
these  cases. 

5.  Stitch  Suppuration. — This  should  not  occur  with 
proper  aseptic  technique,  but  is  sometimes  the  result  of 
too  much  tension  on  a  stitch.  When  this  is  the  case, 
the  offending  stitch  should  be  divided,  so  as  to  relieve 
the  tension.  The  stitch  should  not  be  removed,  for  fear 
of  carrying  septic  material  into  the  deeper  parts  of  the 
wound.  When  the  abdominal  wall  has  been  sewn  up 
in  layers,  suppuration  of  the  deep  stiches  is  a  very 
troublesome  complication.  This  is  the  great  objection 
to  all  buried  sutures.     That  it  is  not  always  the  result 


1 86     The   After-Treatment   of  Operations 

of  the  suture  material  being  septic  is  certain,  as  occa- 
sionally a  sinus  will  form,  leading  down  to  the  deep 
sutures,  months  after  the  wound  has  healed  up.  When 
this  is  the  case,  the  old  wound  must  be  opened  and  all 
the  stitches  removed. 

Any  persistent  sinus  which  refuses  to  heal  should  be 
carefully  investigated  for  the  presence  of  a  foreign  body, 
such  as  a  stitch,  piece  of  drainage-tube,  lost  swab,  etc., 
as  this  is  by  far  the  most  common  cause  of  such  sinuses. 

6.  FiBcal  Fistula.  —  Faecal  fistula  is  most  commonly 
seen  after  operations  for  appendicitis,  and  is  then  due  to 
an  opening  either  in  the  remains  of  the  appendix  or  in 
the  caecum.  The  first  thing  to  do  is  to  make  sure  that 
there  is  free  drainage  from  the  sinus,  and  that  there  is  no 
danger  of  pocketing.  For  this  purpose  a  drainage-tube 
should  be  kept  in,  and  the  fistula  kept  as  clean  as 
possible.  The  majority  of  these  fascal  sinuses  close 
spontaneously  in  the  course  of  a  month  or  six  weeks, 
and  often  in  much  less  time  than  this.  If  there  is  any 
tendency  to  the  formation  of  a  bottle  shaped  cavity,  the 
external  opening  should  be  carefully  dilated  or  enlarged 
by  cutting,  and  the  wound  drained  from  the  bottom. 
The  diet  should  be  regulated  so  that  it  may  be  easily 
digested,  and  the  patient  should  be  kept  in  bed,  and,  if 
possible,  in  such  a  position  that  the  intestinal  contents 
do  not  tend  to  flow  into  the  fistula,  but  rather  to  pass  by 
the  natural  channel.  When,  in  spite  of  these  measures, 
the  t:stula  will  not  close,  it  generally  means  that  there  is 
some  obstruction  to  the  flow  of  faeces  from  the  part  of 
the  intestine  above  the  fistula  into  that  below  it ;  and  this 
should  be  investigated,  and,  if  an  obstruction  is  found, 
an  operation  must  be  performed  to  remove  it,  or  to 
anastomose  the  intestine  above  and  below  the  fistula,  or 
whatever  else  may  seem  mo5t  suitable, 


Operations  on   the  Abdomen        187 

As  these  fistulas,  however,  often  close  of  themselves 
after  existing  for  several  months,  it  is  as  well  to  wait  for 
some  time  before  trying  to  close  them  by  operation, 
unless  there  is  obvious  obstruction  and  all  the  faecal 
material  is  passing  by  the  wound.  In  cases  of  faecal 
fistula  not  connected  with  the  appendix  or  operations  for 
its  removal,  the  same  remarks  apply,  but  the  cause  of 
the  persistence  of  the  fistula  may  thein  be  the  formation 
of  a  spur,  and  steps  must  be  taken  for  its  removal.* 

7.  Parotitis. — This  curious  complication  may  occur 
after  any  operation,  but  it  is  most  commonly  seen  after 
laparotomy  and  operations  on  the  pelvic  organs.  It 
seems  to  occur  more  often  in  women  than  in  men. 
Excluding  operations  on  the  pelvic  organs,  it  is  most 
commonly  seen  after  operations  on  the  stomach,  such  as 
for  the  treatment  of  perforated  gastric  ulcer,  etc.  Out 
of  100  cases  collected  by  Mr.  Stephen  Paget,!  the 
following  primary  causes  were  noted  :  Injury  or  disease 
of  the  alimentary  canal,  injury  or  disease  of  the  urinary 
tract,  ditto  of  the  abdominal  wall,  peritoneum,  or  pelvic 
cellular  tissue,  a  blow  on  the  testicle,  the  introduction 
of  a  pessary,  menstruation,  and  parturition.  In  93  per 
cent,  of  the  cases  it  occurred  as  an  isolated  lesion,  no 
other  complication  being  present.  There  was  evidence 
of  a  primary  septic  focus  in  only  fifteen  cases.  The  period 
at  which  it  comes  on  after  the  operation  seems  to  vary 
very  considerably.  The  commonest  time  seems  to  be 
from  a  week  to  ten  days  after  the  operation.  In  some 
cases  the  submaxillary  glands  are  affected  as  well  as  the 
parotids.     The  condition  comes  on  with  great  swelling  of 

*  Foret's  treatment  of  faecal  fistulas.  See  the  author's  book  on 
'  Surgical  Diseases  cf  the  Colon  '  (Bailliere,  Tindall  and  Cox) 

f  '  Parotitis  following  Injury  or  Disease  ' :  Stephen  Paget,  British 
Medical  Journal,  1887,  vol.  i.,  p.  613. 


1 88     The  After-Treatment  of  Operations 

the  parotid  glands,  accompanied  by  the  usual  signs  of 
inflammation.  It  closely  resembles  mumps.  There  is 
often  pain,  and  there  may  be  a  high  temperature.  The 
temperature,  however,  does  not  as  a  rule  exceed  ioo°  F. 
or  101°  F.,  except  in  the  septic  cases. 

The  condition  often  suggests  that  an  abscess  is 
forming ;  as  a  rule,  however,  the  inflammation  subsides 
in  the  course  of  a  day  or  so.  Suppuration,  however, 
may  take  place,  and  the  best  evidence  of  this  will  be  the 
temperature  chart.  The  pus  tends  to  burrow  into  the 
external  auditory  meatus  or  the  pharynx.  The  cause  of 
the  condition  is  very  doubtful.  That  there  is  some 
curious  association  between  the  parotid  gland  and  the 
genital  organs  is  certain,  but  what  this  depends  upon  we 
do  not  yet  know.  The  best  way  of  treating  the  parotitis 
is  by  hot  fomentations  or  lead  lotions,  and  a  smart  purge 
should  be  administered.  If  suppuration  takes  place, 
incisions  must  at  once  be  made  into  the  gland,  care 
being  taken  not  to  wound  the  branches  of  the  facial 
nerve. 

The  exact  cause  of  this  curious  condition  is  still 
uncertain,  but  there  is  some  reason  to  suppose  that  it 
results  from  an  infection  of  Stenson's  duct  consequent 
upon  a  septic  condition  of  the  buccal  cavity.  Careful 
attention  to  the  cleanliness  of  the  patient's  mouth  is 
advised  as  a  preventative  measure. 

The  following  curious  case  of  this  complication  is 
reported  by  Fiske  Jones  (Boston  Medical  and  Surgica-l 
Journal,  November  20,  ig:)2)  : 

A  girl,  aged  nineteen,  had  a  first  attack  of  appendicitis  in  1897. 
An  abscess  developed,  spreading  into  the  pelvis,  which  was  opened 
and  drained  on  the  tenth  day.  Fcrty-eight  hours  after  the  operation 
the  right  parotid  gland  began  to  ache  and  swell.  Two  days  later  the 
left  became  similarly  affected.     Within  a  week  the  pain  and  swell- 


Operations  on   the  Abdomen        189 

ing  began  to  subside.  One  year  afterwards  a  second  attack  of 
appendicitis  occurred.  An  abscess  was  opened  and  drained  forty- 
eight  hours  after  the  onset  of  the  symptoms,  and  two  days  later  the 
right  parotid  became  inflamed,  the  opposite  gland  being  involved 
forty- eight  hours  after  its  fellow.  In  November,  1899,  two  years 
and  a  half  subsequent  to  the  first  seizure,  a  third  attack  occurred  ; 
the  appendix  was  removed,  and  the  pelvis  drained.  Once  more 
the  right  and  then  the  left  parotid  became  inflamed.  There  was 
no  rigor,  and  the  symptoms  were  comparatively  mild. 

8.  Weak  Scav. — Stretching  of  the  scar,  and  the  forma- 
tion of  a  weak  spot  in  the  abdominal  wall,  is  most 
commonly  seen  when  the  wound  is  in  the  area  below  the 
umbilicus,  as  it  is  more  subject  to  pressure  in  this 
situation.  A  weak  scar  is  most  often  seen  after  opera- 
tions for  the  drainage  of  a  septic  cavity,  and  especially 
after  operations  for  tubercular  peritonitis  or  tubercular 
lesions  of  the  appendix.  It  must  be  treated  by  strapping 
the  sides  of  the  scar  firmly  together  with  adhesive 
plaster,  and  making  the  patient  wear  a  properly-fitting 
abdominal  belt.  There  must  on  no  account  be  a  pad  on 
the  belt  to  press  on  the  scar,  as  such  pressure  is  liable 
to  cause  atrophy  of  the  tissues,  and  will  tend  to  still 
further  weaken  the  scar.  In  some  cases,  especially  in 
children,  it  is  better  to  keep  the  patients  in  bed  for  a 
time  until  the  scar  has  to  some  extent  consolidated,  and 
then  to  let  them  get  up  with  a  belt,  which  should  be 
worn  for  six  months  or  more. 

g.  Intestinal  Obstruction. — Intestinal  obstruction  is  an 
accident  that  may  follow  any  abdominal  operation,  but  it 
is  most  common  after  operations  on  the  pelvic  organs. 
It  is  also  not  infrequently  seen  after  operations  upon  the 
appendix.  The  symptoms  generally  commence  with 
colicky  pains  in  the  abdomen,  accompanied  by  distension 
and  sickness.  There  is  also  increasing  difficulty  in 
getting  the  bowels  to  act.     The  patient  may  have  been 


190     The  After-Treatment  of  Operations 

going  on  quite  satisfactorily  for  the  first  three  or  four 
days  after  the  operation,  and  the  bowels  have  been 
opened  on  the  third  day  by  means  of  enemata,  and  then 
something  appears  to  go  wrong.  There  is  constipation, 
accompanied  by  colicky  pains,  and  great  difficulty  is 
experienced  in  getting  the  bowels  to  act.  This  difficulty 
increases,  until  in  a  very  short  time  there  is  absolute 
obstruction,  and  the  ordinary  symptoms  of  acute  intes- 
tinal obstruction  are  developed.  The  condition  is  most 
commonly  seen  about  five  or  six  days  after  the  operation. 
Although  the  symptoms  develop  slowly,  the  condition 
when  once  established  is  usually  that  of  an  acute  obstruc- 
tion. The  pathology  of  the  obstruction  in  these  cases 
is  probably,  that  a  coil  of  intestine  becomes  adherent  to 
some  portion  of  the  field  of  operation,  and  kinking  takes 
place  in  consequence.  At  first  only  slight  narrowing  of 
the  intestinal  lumen  results,  but  as  the  intestine  above 
gets  more  and  more  distended,  the  obstruction  increases, 
until  often  it  becomes  absolute. 

As  soon  as  ever  the  symptoms  show  themselves,  and 
this  condition  is  suspected,  prompt  measures  must  be 
taken  for  its  relief.  At  first  an  attempt  should  be  m,ade 
to  stretch  or  detach  the  adhesions  by  causing  peristalsis 
of  the  intestine.  Large  doses  of  salines  may  be  adminis- 
tered by  the  mouth,  and  turpentine  enemata  administered 
by  the  rectum.  Sir  Watson  Cheyne  "  draws  attention  to 
the  value  of  position  in  the  treatment  of  this  condition. 
He  advises  that  the  patient  should  be  placed  in  such  a 
position  that  a  certain  amount  of  dragging  is  produced 
upon  the  adherent  coil  of  intestine.  Thus,  the  buttocks 
should  be  raised,  and,  in  fact,  the  patient  placed  in  a 
modified  Trendelenburg  position.  Should  these  measures 
not  prove  sffectual  in  getting  rid  of  the  obstruction,  time- 
*  '  Surgical  Treatment ' :  Cheyne  and  Burghard,  vol.  vi. 


Operations   on   the  Abdomen        191 

must  not  be  wasted,  but  the  abdomen  should  be  at  once 
reopened,  and  the  adherent  coll  detached  from  the  part 
to  which  it  has  become  adherent.  Once  the  diagnosis  of 
secondary  obstruction  has  been  made,  the  best  treatment 
is,  undoubtedly,  to  at  once  reopen  the  abdomen  through 
the  original  incision.  The  cause  is  most  likely  to  be  some 
adhesion  of  bowel  to  the  incision  or  its  strangulation  in  a 
stitch.  The  patient  should  not  be  exhausted  by  drastic 
attempts  at  purgation  before  operation  is  resorted  to. 

The  following  list  shows  the  causes  found  in  26  cases 
of  post-operative  intestinal  obstruction  collected  by 
G.  M.  T.  Finney:*  Kinking,  7  cases;  adhesions  alone,  7; 
bands,  3  ;  volvulus,  2  ;  loop  caught  beneath  adherent 
loop,  I ;  cicatricial  stenosis,  i ;  gastro-mesenteric  ileus,  i  ; 
adynamic  ileus,  i  ;  cause  unknown,  3,  Ten  of  the 
patients  died,  the  remainder  recovering  as  the  result  of 
a  secondary  operation. 

The  following  cases  well  illustrate  the  importance  of 
prompt  surgical  interference  : 

Case. — S.  W.  was  operated  upon  for  colotomy  on  June  6,  and 
on  the  second  day  after  the  operation  the  bowel  was  opened  and 
castor-oil  administered  by  the  mouth.  No  action  of  the  bowels 
took  place,  and  vomiting  began  twenty-four  hours  later,  and  became 
severe.  Further  attempts  at  purgation  only  increased  the  vomiting 
without  relieving  the  bowels.  On  June  10  the  abdomen  was  re- 
opened, when  it  was  found  that  a  piece  of  omentum  was  caught  in 
the  spur  stitch,  and  the  drag  on  this  was  causing  an  acute  kink  in 
the  transverse  colon.  This  was  released,  but  the  patient  died 
on  the  operating  table.  The  operation  should  have  been  done 
earlier. 

Case. — A.  M.  was  operated  upon  for  chronic  appendicitis,  the 
appendix  being  removed,  and  the  abdomen  closed  without  drainage. 
Two  deep  stitches  of  fish-gut  were  put  through  all  the  thicknesses 
of  the  abdominal  wall,  as  well  as  supporting  stitches.     The  patient 

*  Any.als  of  Suvgcry,  June,  1906. 


192     The  After-Treatment  of  Operations 

did  well  for  twenty- four  hours,  but  then  began  to  get  much  dis- 
tended, and  all  efforts  to  open  the  bowels  failed.  The  abdomen 
was  reopened  on  the  third  day  through  the  original  incision,  when 
it  was  found  that  a  piece  of  the  wall  of  the  small  bowel  was  caught 
under  one  of  the  deep  stitches  and  strangulated.  This  was  released, 
and  the  damaged  patch  of  bowel  inverted  by  stitches.  The  patient 
made  a  good  recovery. 

10.  Adhesions. — Adhesions,  though  they  may  not  cause 
actual  intestinal  obstruction,  are  not  infrequently  the 
cause  of  very  considerable  trouble  after  some  abdominal 
operations,  more  especially  those  which  have  been  done 
for  some  inflammatory  mischief.  After  the  convalescent 
period  following  the  operation  has  passed,  the  patient 
begins  to  get  vague  pains  in  the  abdomen.  These  pains 
are  often  accentuated  by  walking  and  exercise.  There  is 
increasing  difficulty  in  getting  the  bowels  to  act,  and 
aperient  medicines  have  to  be  constantly  taken.  Colicky 
pains  often  accompany  any  action  of  the  bowels,  and  in 
some  cases  the  patient  gets  considerable  pain  in  the 
lower  part  of  the  abdomen  if  the  bladder  is  allowed  to 
become  distended.  These  symptoms  often  increase  in 
severity  and  may  make  the  patient  a  chronic  invalid. 
The  symptoms  are  due  to  adhesions  between  different 
portions  of  the  intestine  or  between  the  intestines  and 
other  organs. 

Sometimes  the  symptoms  can  be  cured  by  massage 
and  suitable  exercises  in  a  gymnasium,  and  considerable 
relief  usually  follows  this  line  of  treatment. 

In  some  of  the  old-standing  cases  however  it  may 
be  necessary  to  open  the  abdomen  and  divide  the 
adhesions. 

Illustrative  Case. — A  woman,  aged  thirty,  was  operated  upon  for 
perforating  appendicitis  with  a  small  abscess  in  the  right  iliac  fossa. 
She  had  had  three  previous  attacks  of  appendicitis  of  less  severity. 
She  recovered  from  the  operation  perfectly  well,  and  had  no  com- 


Operations  on   the  Abdomen        193 

plications.  She  made,  in  fact,  an  uninterrupted  recovery,  and  for 
a  time  was  lost  sight  of.  When  heard  of  two  years  later,  she  said 
she  had  had  increasing  difficulty  with  the  bowels  since  the  opera- 
tion, and  that  she  had  constantly  to  take  medicine  before  she  was 
relieved.  She  was  unable  to  stand  for  more  than  one  or  two  hours 
without  getting  severe  pains  in  the  abdominal  region,  and  had 
frequently  to  go  and  lie  down.  She  was  also  unable  to  hold  her 
urine  for  any  length  of  time  without  pain.  All  her  symptoms 
pointed  to  adhesions  in  the  neighbourhood  of  the  right  iliac  fossa. 
Careful  regulation  of  the  bowels  and  suitable  massage  and  exercises 
were  effectual  in  getting  rid  of  all  her  symptoms. 

11.  Ventral  Hernia. — A  hernia  through  the  scar  is  a 
possibiHty  after  any  laparotomy  if  a  large  incision  has 
been  made.  The  modern  practice  of  opening  the 
abdomen  by  splitting  the  muscles  and  closing  it  in 
layers  has  done  much  to  prevent  the  occurrence  of  this 
complication.  It  was  a  not  uncommon  complication  when 
the  usual  practice  was  to  close  the  abdominal  wound 
with  a  single  row  of  sutures.  It  is  particularly  liable  to 
occur  if  the  wound  does  not  close  by  first  intention. 
When  a  hernia  occurs  the  effect  of  a  properly  fitting 
belt  should  be  tried  for  a  time,  and  if  no  improvement 
follows,  an  operation  to  close  the  defect  should  be  under- 
taken. 

12.  Post-operative  Acute  Dilatation  of  the  Stomach. — This 
most  serious  complication  may  occur  after  any  operation 
involving  the  abdominal  cavity.  It  may  come  on  at 
once  or  after  some  days.  Vomiting  is  usual,  but  not 
invariable.  The  distension  is  very  great,  and  the  patient 
rapidly  becomes  very  ill. 

In  many  cases  death  occurs  in  the  course  of  two  or 
three  days,  but  cases  of  recovery  are  known.  There 
is  usually  no  obstruction  found  post  mortem,  though 
in  one  or  two  instances  internal  herniae  have  been 
found. 

The  best  treatment  would  seem  to  be  lavage  cf  the 

13 


194    The  After-Treatment  of  Operations 

stomach  with  a  stomach -tube  two  or  three  times  a  day 
till  the  distension  passes  off,  and  subcutaneous  infusion 
with  saline  solution. 

Operation  is  not  indicated  as  a  rule,  but  gastro- 
enterostomy has  been  done  successfully  in  one  or  two 
cases. 

Illustrative  Case. — A  man  aged  fifty-eight  was  operated  on  for  a 
;eft  inguinal  hernia  after  forty-eight  hours  careful  preparation  for 
operation.  The  Trendelenburg  position  was  used  for  about  twenty 
minutes  during  the  operation.  After  operation  gastric  distension 
came  on  rapidly.  There  was  no  vomiting.  Relief  followed  the 
use  of  the  stomach-tube,  and  it  was  used  about  twice  daily  for 
some  days. 

The  patient  recovered.  Six  months  later  he  was  again  operated 
on  for  a  right  inguinal  hernia,  and  the  same  symptoms  occurred, 
though  on  this  occasion  local  anaesthesia  with  cocaine  was  used. 

13.  Foreign  Bodies  left  in  the  Abdomen. — Leaving  a  foreign 
body  inside  the  abdomen  after  an  operation  is  a  most 
unfortunate  accident,  and  one  which  should  never  occur. 
As  long,  however,  as  it  is  human  to  err,  such  accidents 
will  occasionally  take  place,  and  it  is  only  by  the  adoption 
of  systematic  methods  that  they  can  be  prevented. 

The  foreign  bodies  which  have  been  left  behind  are 
various,  and  include  clips,  scissors,  sponges,  swabs, 
pieces  of  rubbgr-tubing,  etc.  Sponges  and  swabs  have 
been  known  to  become  encysted,  and  to  have  remained 
for  long  periods  in  the  abdominal  cavity  without  causing 
any  symptoms,  and  have  sometimes  been  mistaken  for 
tumours  at  a  later  date.  This  is,  however,  by  no  means 
always  the  case,  and  very  serious  complications  may 
follow  the  leaving  of  such  foreign  bodies  in  the  abdomen. 
Ulceration  into  the  bowel  or  some  other  hollow  viscus 
may  follow,  and  may  prove  fatal ;  or  an  abscess  may 
form  beneath  the  skin,  and  a  sinus  develop  down  to  the 
foreign  body.     There  are  a  few  cases  on  record  where 


Operations  on  the  Abdomen        195 

such  foreign  bodies  have  been  spontaneously  discharged 
from  an  abscess.  Instruments  left  behind  are  certain  to 
give  rise  to  very  serious  complications. 

The  best  way  of  preventing  an  accident  of  this  kind 
is  to  adopt  a  form  of  operative  technique  that  does  not 
allow  the  possibility  of  any  mistake. 

The  mere  counting  of  sponges  and  swabs  after  an 
operation  is  not  by  itself  sufficient.  A  potent  cause  of 
such  accidents  is  the  practice  of  cutting  in  half  sponges 
or  swabs  during  the  operation,  or  of  cutting  off  pieces  of 
gauze  to  pack  round  a  stump  or  to  arrest  haemorrhage. 
This  should  never  be  done.  It  is  very  liable  to  result  in 
something  being  left  behind,  and  counting  the  sponges 
or  swabs  afterwards  will  not  prevent  this  if  the  number 
has  been  changed  in  the  course  of  operation. 

The  best  plan,  if  sponges  are  used,  is  to  use  only  three 
or  six,  and,  if  more  are  necessary,  to  have  them  in 
multiples  of  three  ;  then,  if  at  the  en-d  of  the  operation 
the  sponges  are  still  in  multiples  of  three,  none  can  be 
left  behind.  The  surgeon  should  himself  be  responsible 
for  counting  the  sponges. 

Another  and  safer  plan  is  to  use  square  sterilized 
cloths  instead  of  sponges,  with  a  piece  of  tape  sewn  to 
one  corner.  The  end  of  the  tape  is  clipped  and  left 
hanging  down  outside  the  wound.  These  sterilized 
cloths  are  better  than  sponges  for  packing  off  the  field 
of  operation,  and  if  used  in  this  way  cannot  be  left 
behind. 

Another  very  good  plan  is  to  use  the  end  of  a  roll  of 
sterilized  gauze  to  pack  round  the  site  of  operation,  the 
roll  itself  being  kept  on  the  towels,  and  more  gauze 
unwound  as  it  is  needed,  but  the  gauze  never  cut.  The 
portion  of  gauze  at  the  edge  of  the  wound  can  be  used 
for  swabbing.    As  the  whole  of  the  gauze  in  use  is  in  one 


196     The  After-Treatmcnt  of  Operations 

continuous  piece,  it  is  quite  impossible  for  any  of  it  to  be 
left  behind  so  long  as  it  is  not  cut. 

The  clips  used  in  the  operation  should  be  in  dozens 
or  half-dozens,  and  should  be  counted  before  and  after 
the  operation  by  the  surgeon  himself.  The  plan  of  using 
a  porcelain  rack  with  numbered  holes  for  the  clips,  as 
suggested  by  Mr.  Marmaduke  Sheild  [Lancet,  June  11, 
1904),  is  an  excellent  method  of  preventing  this  untowar  J 
accident. 


Fig.  28. 


Abdominal  Belts  for  Use  after  Laparotomy. — 
There  are  many  different  kinds  of  belts,  and  the  exact 
form  is  not  of  much  importance.  The  principal  points 
of  a  good  belt  are  an  accurate  fit  and  a  good  support  to 
the  lower  part  of  the  abdomen  immediately  over  the 
pelvic  brim.  A  belt  which  constricts  the  abdomen  with- 
out supporting  it  is  bad,  and  will  do  more  harm  than 
good.     A  good  form  of  belt  is  shown  in  Fig.  28. 


CHAPTER  XIV 
OPERATIONS  ON  THE  ABDOMEN  {continued) 

Cases  of  Acute  General  Peritonitis. 

The  modern  method  of  treating  such  cases  is  to  deaV 
with  the  cause  of  the  infection  as  rapidly  and  effectually 
as  possible,  and  to  drain,  by  means  of  tubes,  those 
portions  of  the  abdominal  cavity  in  which  pus  tends  to 
collect.  Everything,  however,  depends  on  the  after- 
treatment  in  these  cases.  The  patient  should  from  the 
first  be  nursed  in  what  has  been  called  the  Fowler 
position — that  is  to  say,  in  the  semi-sitting  position  shown 
on  p.  6.  In  this  position  the  pus  and  serous  discharge 
will  gravitate  into  the  pelvis,  where  they  can  escape,  and 
away  from  the  upper  and  more  dangerous  areas  of  the 
abdomen.  The  patient  should  be  kept  in  this  position 
throughout,  and  must  not  be  allowed  to  assume  the 
horizontal  position  until  the  peritonitis  has  subsided. 

The  other  important  point  is  to  administer  large 
quantities  of  saline  solution  by  the  rectum.  The  best 
plan  is  to  arrange  continuous  rectal  irrigation.  This  is 
done  by  means  of  an  ordinary  irrigator  or  douche  with  a 
vaginal  nozzle,  which  is  passed  into  the  rectum.  The 
top  of  the  fluid  in  the  irrigator  should  not  be  more  than 
6  inches  above  the  level  of  the  anus,  so  that  the  fluid 
runs  in  slowly.     The  irrigator  must  be  kept  full  of  warm 

197 


198     The  After-Treatment  of  Operations 

saline  solution.  From  10  to  20  pints  should  be  allowed 
to  absorb  from  the  bowel  during  the  first  twenty-four 
hours,  and  continued,  if  necessary.  This  is  a  most 
valuable  means  of  treating  acute  peritonitis,  as  it  washes 
out  the  poisons  in  the  blood  and  tissues  and  helps  their 
elimination. 

The  dressings  should  be  changed  frequently,  and  the 
drainage-tubes  shortened  and  ultimately  removed  as 
soon  as  the  discharge  from  them  gets  less  or  ceases. 

It  seems  certain  that  the  drainage  of  the  peritoneal 
cavity  by  means  of  tubes  is  not  effective  for  more  than 
about  twenty-four  or  forty-eight  hours,  and  there  is,  there- 
fore, nothing  to  be  gained  by  leaving  the  tubes  in  for 
more  than  two  or  three  days. 

Very  little,  if  any,  food  should  be  given  by  the  mouth 
for  the  first  two  days,  but  nutrient  liquids  may  be  added 
to  the  rectal  irrigating  fluid  from  time  to  time. 

The  bowels  should  be  moved  as  soon  as  possible  by 
means  of  castor -oil  or  calomel,  and  should  be  kept 
acting  freely  during  convalescence,  so  as  to  prevent,  as 
far  as  possible,  the  formation  of  adhesions. 

Operations  on  the  Stomach. 

Special  Complications.  —  (i)  Pneumonia;  (2)  re- 
gurgitant vomiting  ;  (3)  haematemesis. 

I.  Pneumonia.- — One  of  the  commonest  causes  of  death 
after  operations  on  the  stomach,  and  more  especially 
operations  undertaken  for  the  relief  of  pyloric  stenosis,  is 
pneumonia.  The  reason  for  this  is  that  the  patients  are 
often  old  or  enfeebled  subjects,  and  that  the  free  move- 
ment of  the  upper  abdominal  muscles  and,  to  some  extent, 
the  diaphragm  are  interfered  with  owing  to  the  incision. 
The  respirations  in  consequence  are  shallow,  as  the 
patient  is  afraid  of  the  pain  caused  by  a  deep  inspiration, 


Operations  on  the  Abdomen        199 

Coughing  is  for  the  same  reason  prevented,  and,  as  a 
result,  mucus  collects  in  the  most  dependent  parts  of  the 
lungs  and  sets  up  hypostatic  pneumonia.  The  best  way 
of  preventing  this  is  to  nurse  the  patient  as  far  as  possible 
in  a  sitting  position  ;  the  knees  should  be  flexed  over  a 
cushion  or  bolster,  and  the  back  and  head  supported  with 
a  bed-rest  and  pillows. 

A  good  way  of  preventing  pulmonary  trouble  after 
operations  on  the  abdomen  is  to  instruct  the  nurse  to  get 
the  patient  to  take  a  few  deep  breaths  so  as  to  com- 
pletely fill  the  chest  every  few  hours. 

2.  Regurgitant  Vomiting. — This  sometimes  follows  the 
operation  of  gastro-enterostomy.  When  it  comes  on 
about  two  or  three  days  after  the  operation  and  there  are 
no  signs  of  peritonitis,  it  is  usually  due  to  the  formation 
of  the  so-called  '  vicious  circle ' — that  is  to  say,  a  kink 
has  formed  in  the  intestinal  loop,  and  the  contents  of  the 
stomach,  instead  of  passing  into  the  distal  portion  of  the 
intestine,  are  passing  into  the  proximal  or  duodenal  por- 
tion, and  so  back  into  the  stomach  (Figs.  29  and  30). 
This  should  be  especially  suspected  if  there  is  much  bile 
present  in  the  vomit.  It  used  to  be  supposed  that  the 
presence  of  bile  in  the  stomach  was  the  cause  of  the 
vomiting,  but  it  has  now  been  shown  that  this  is  not  the 
case.  The  vomiting  is  probably  always  due  to  some 
blockage  in  the  new  anastomotic  opening,  which  may  be 
of  either  a  temporary  or  permanent  nature.  The  vomiting 
may  be  but  slight,  occurring  only  a  few  times  and  then 
ceasing  altogether,  or  it  may  be  so  serious  as  to  quickly 
cause  a  fatal  issue.  When  regurgitant  vomiting  occurs, 
the  stomach  should  be  washed  out,  and  all  feeding  by  the 
mouth  stopped  for  a  time.  Changing  the  patient's  position 
is  sometimes  effectual  in  freeing  the  bowel.  Thus,  if  the 
patient  has  been  propped  up  he  should  be  made  to  lie  down 


2co     The  After-Treatment  of  Operations 


Fig.  29.  — Formation  of  a  '  Vicious 
Circle  '  after  Anterior  Gas- 

TRO  -  enterostomy,     DUE     TO      A 

Faulty  Operation  and  Peri- 
stalsis occurring  in  Opposite 
Directions  in  the  Stomach 
AND  Intestine. 


Fig.  30. — Formation  of  a  '  Vicious 
Circle'  after  Anterior  Gas- 
tro-enterostomy,  due  to  the 
Formation  of  a  Spur  by  the 
Drag  of  the  Intestine. 


Fig.  31. — Method  of  Curing  a 
'  Vicious  Circle  '  by  Anasto- 
mosis between  the  Afferent 
and  Efferent  Loops  of  Intes- 
tine. This  is  the  best  Opera- 
tion IN  Cases  where  a  'Vicious 
Circle  '  has  formed  and  a 
Secondary  Operation  has 
become  necessary  for  its 
relief. 


Fig.  32. — Another  Method 
of  Curing  or  Preventing 
A  'Vicious  Circle.'  The 
Y  Operation. 


operations  on   the   Abdomen        201 

flat  on  his  back  so  as  to  prevent  the  drag  on  the  loop  of 
intestine.  Giving  the  patient  large  draughts  of  water  to 
drink  has  occasionally  stopped  the  vomiting.  The  bowels 
should  also  be  got  to  act  well.  If  these  measures  fail  to 
stop  the  vomiting,  another  operation  should  at  once  be 
performed  to  make  a  free  exit  for  the  stomach  contents 
into  the  bowel.  Probably  the  best  operation  to  perform 
under  these  circumstances  is  to  anastomose  the  loop 
between  the  pylorus  and  stomach  to  the  distal  portion 
of  the  intestine  lower  down  (Fig.  31).  In  slight  cases 
of  regurgitant  vomiting,  lavage  of  the  stomach  every 
twenty-four  hours  will  give  rehef ;  in  bad  cases  opera- 
tion must  be  at  once  resorted  to.  When  persistent 
vomiting  follows  other  operations  on  the  stomach  than 
gastro-enterostomy,  it  is  probably  due  to  acute  gastritis 
or  peritonitis,  and  must  be  treated  accordingly. 

3.  HcBmatemesis. — Vomiting  of  blood  after  operations 
on  the  stomach  is  not  at  all  uncommon  for  the  fir^t 
twenty-four  or  forty-eight  hours.  It  is  generally,  how- 
ever, only  the  blood  which  has  got  into  the  stomach  at 
the  time  of  the  operation,  and  need  not  cause  alarm. 
When,  however,  the  blood  is  bright  in  colour,  and  there 
is  reason  to  suppose  that  it  is  the  result  of  oozing  from 
the  stomach  wound,  a  little  hot  water  may  be  given  to 
drink  with  a  view  to  stopping  it,  or  the  stomach  may  be 
gently  irrigated  with  warm  boracic  lotion  by  means  of  a 
soft  tube.  It  is  seldom  that  the  bleeding  is  of  any  con- 
sequence. 

Position  after  Operations  on  the  Stomach. — The 
best  position  in  most  cases  is  the  half-sitting  position 
already  mentioned,  but  the  exact  position  must  depend 
upon  the  nature  of  the  lesion  and  its  site  in  the  stomach. 
Thus,  in  many  cases  our  object  should  be  to  keep  the 
patient  in  that  position  which  will  allow  of  fluids,  etc., 


20  2     The  After-Treatinent  of  Operations 

most  easily  finding  an  exit  from  the  stomach  into  the 
intestines.  Since  the  pylorus  is  to  the  right  side,  the 
right  lateral  position  is,  in  many  cases,  advisable,  and 
is  always  to  be  preferred  to  the  left  lateral  or  supine 
positions.  The  power  of  the  stomach  to  expel  its  contents 
is  usually  very  feeble  after  any  operation  upon  its  walls, 
and  we  must  try  to  assist  it,  as  far  as  possible,  by  means 
of  gravity. 

It  is  an  excellent  plan  when  patients  are  being  nursed 
in  the  sitting  position  to  allow  them  to  sleep  at  night  in 
the  right  lateral  recumbent  position.  They  not  only 
sleep  better  in  this  position,  but  it  prevents  the  accumula- 
tion of  fluids  in  the  stomach,  and  insures  free  drainage 
from  that  organ  into  the  intestine  during  the  night. 
Moving  the  patient's  position  from  time  to  time  also 
tends  to  prevent  the  formation  of  bed-sores,  which  are 
otherwise  very  liable  to  form  m  the  case  of  old  and 
emaciated  subjects. 

Again,  in  the  case  of  ulcers  which  have  been  treated 
surgically,  we  must  try  to  keep  the  patient  in  such  a 
position  that  the  wound  will  not  be  in  a  dependent  part 
of  the  stomach,  and  so  will  not  be  constantly  in  contact 
with  the  contents,  be  it  food  or  mucus. 

As  in  these  cases  it  is  particularly  desirable  that  there 
should  not  be  any  vomiting  after  the  operation,  owing  to 
the  strain  which  it  might  throw  upon  the  stitches  in  the 
wall  of  the  stomach,  it  is  best  not  to  give  anything  by 
the  mouth  for  the  first  twenty-four  or  forty-eight  hours, 
and  rectal  feeding  should  be  adopted.  Patients  often 
complain  of  great  thirst ;  this  must  be  appeased  by 
giving  warm  water  enemata,  and  sometimes  a  thin  slice 
of  lemon  to  suck  will  make  the  patient  more  comfortable. 
When  the  patient  is  old  or  much  enfeebled  as  the  result 
of  his  condition  previous  to  the  operation,  it  is  often  not 


Operations  on  the  Abdomen        203 

wise  to  depend  entirely  on  rectal  feeding  even  for  the 
first  two  days,  and  he  should  be  given  small  quantities 
of  fluid  diet,  such  as  albumin-water  every  two  or  three 
hours,  as  soon  as  the  results  of  the  anaesthetic  have 
passed  off.  The  diet  should  be  entirely  fluid  for  the  first 
five  days  or  a  week  after  the  operation.  The  sugar  diet 
already  mentioned  is  a  very  suitable  one  in  stomach 
cases,  and  may  be  combined  with  albumin-water.  The 
wound  in  the  stomach  wall  is  probably  healed  at  the  end 
of  a  week  or  ten  days.  Mr.  Barker*  recommends  that 
when  the  patient  after  an  operation  on  the  stomach 
complains  of  a  feeling  of  weight  and  distension  in  the 
region  of  the  stomach,  a  soft  tube  should  be  passed 
and  the  fluids  contained  in  the  stomach  siphoned  off. 
He  says  that  very  marked  relief  from  pain  and  discom- 
fort often  follows  this  procedure ;  it  may  be  employed 
during  the  first  twenty-four  hours,  and  repeated  if  neces- 
sary. 

Operations  on  the  Gail-Bladder  and  Biliary 
Ducts. 

Special  Complications.  —  (i)  Haemorrhage;  (2) 
biliary  fistula ;  (3)  broncho-pneumonia  and  pleurisy ; 
(4)  acute  dilatation  of  the  stomach  ;  (5)  vomiting. 

I.  Hamonhage. — Many  of  these  operations  have  of 
necessity  to  be  performed  upon  patients  who  are  suffer- 
ing from  jaundice,  and  the  coagulability  of  the  blood 
under  these  conditions  seems  to  be  altered  in  much 
the  same  way  as  is  the  case  in  patients  the  subject  of 
haemophilia.  Oozing  from  all  parts  of  the  wound  takes 
place,  and  if  not  stopped  often  proves  fatal.  This 
oozing  may  not  come  on  for  two  or  three  days  after  the 
*  Lancet,  August  22,  1902. 


204    The  After-Treatment  of  Operations 

operation.  The  value  of  calcium  salts  by  mouth  or 
rectum  as  a  means  of  preventing  hsemorrhage  in  these 
cases  seems  very  doubtful,  and  many  surgeons  have  given 
it  up.  Moynihan  now  advises  the  use  of  horse  or  rabbit 
serum,  of  which  20  c.c.  are  injected  subcutaneously  five 
or  six  hours  before  operation.  Thyroid  extract  has  also 
been  used  to  shorten  the  blood  coagulability  time  in  these 
cases  with  success. 

2.  Biliary  Fistula. — This  is  an  extremely  troublesome 
affection,  which  occasionally  follows  operations  on  the 
gall-bladder.  As  a  rule,  these  fistulae  close  spontane- 
ously in  the  course  of  a  month  or  two.  When,  however, 
this  is  not  the  case,  it  is  generally  due  to  there  being  a 
block  in  the  common  duct,  either  from  an  impacted 
stone,  malignant  disease  of  the  head  of  the  pancreas,  or 
as  the  result  of  adhesions,  and,  if  possible,  a  further 
operation  should  be  performed  for  its  relief. 

When  the  biliary  fistula  is  accompanied  by  absence  of 
bile  in  the  stools,  as  shown  by  clay-coloured  faeces,  it  is 
practically  certain  that  the  cause  of  the  fistula  is  a  block 
lower  down  in  the  biliary  passages,  and  a  second 
operation  must  be  performed.  When,  however,  there  is 
a  certain  amount  of  bile  in  the  faeces,  it  is  better  to  wait 
for  some  time,  to  see  whether  the  fistula  will  close 
spontaneously. 

3.  Broncho -pneumonia  and  Pleurisy.  —  These  complica- 
tions often  result  from  the  interference  with  the  move- 
ments of  the  diaphragm  caused  by  the  operation.  They 
are  best  guarded  against  by  nursing  the  patient  in  a 
semi-recumbent  position. 

4.  Acute  Dilatation  of  the  Stomach. — This  is  said  to  have 
followed  the  operation  of  choledochotomy  in  some  cases. 
It  is  best  treated  by  gastric  lavage  and  rectal  feeding. 

5.  Vomiting. — It  may  be  mentioned  here  that  persistent 


Operations  on  the  Abdomen        205 

vomiting  may  occur  after  these  operations  when  a  large 
gauze  plug  has  been  inserted.  The  vomiting  often  ceases 
after  removal  of  the  plug. 

Operations  for  Appendicitis. 

Complications.  —  (i)  Peritonitis;  (2)  meteorism  ; 
(3)  faecal  fistula  ;  (4)  empyema  ;  (5)  thrombosis ; 
(6)  infarction  of  the  lung  ;  (7)  loculation  of  pus ; 
(8)  adhesions. 

The  treatment  of  the  wound  is  the  same  as  for  any 
other  abscess,  but  it  is  very  important  that  the  drainage- 
tube  should  not  be  left  out  until  all  the  deeper  parts  of 
the  wound  have  healed,  as  otherwise  the  opening  in 
the  skin  is  very  liable  to  contract  and  allow  the  pus 
to  pocket.  Sometimes  a  week  or  ten  days  after  the 
operation,  when  the  patient  is  apparently  almost  well 
again,  there  is  a  rise  in  temperature  and  pain  at  the  site 
of  the  wound — in  fact,  a  recurrence  of  the  original 
symptoms.  This  usually  means  that  another  abscess 
has  formed  in  the  deeper  parts  of  the  wound  cavity  ;  in 
other  words,  some  pus  has  pocketed,  and  got  shut  oft 
from  the  rest  of  the  wound.  Under  these  circumstances 
the  wound  should  be  carefully  dilated  and  explored  with 
the  finger  or  a  director  until  the  pus  is  found,  and  given 
a  free  exit.  Great  caution  must,  however,  be  exercised 
in  doing  this,  or  there  will  be  danger  of  opening  the 
general  peritoneal  cavity  and  setting  up  peritonitis. 

The  rectal  tube  should  always  be  used  after  the 
operation  as  a  precautionary  measure  against  distension. 
It  is  particularly  in  these  cases  that  distension  and 
meteorism  are  liable  to  occur.  The  patient  should  have 
the  tube  placed  through  the  sphincters,  and  left  in  for 
one  hour  in  six  hours,  commencing  soon  after  the  opera- 
tion (see  page  171). 


2o6     The   After-Treatment  of  Operations 

It  is  most  important,  after  all  operations  for  appendi- 
citis, to  get  the  bowels  to  act  as  soon  as  possible.  An 
enema  should  be  administered  on  the  day  after  the 
operation,  and,  if  it  fails  to  act,  should  be  followed  by  a 
dose  of  salts  or  castor  oil. 

In  cases  where  there  is  a  large  foul  abscess  cavity  left 
after  the  operation,  it  should  be  irrigated  daily  or  twice 
daily.  Care  must  be  taken,  however,  to  irrigate  gently 
and  to  allow  a  free  exit  for  the  fluid,  as  otherwise  there 
is  some  risk  of  forcing  the  fluid  into  the  general  peritoneal 
cavity,  and  so  perhaps  causing  general  peritonitis.  There 
is  no  advantage,  as  a  rule,  in  using  antiseptic  solutions  for 
irrigating  the  abscess  cavity.  In  most  cases  the  best  fluid 
for  the  purpose  is  normal  saline  solution ;  in  cases  where 
the  abscess  cavity  is  very  foul  and  sloughy,  hydrogen 
peroxide  is  often  very  useful  in  cleaning  up  the  wound  ;  it 
should  be  used  of  a  strength  of  5  volumes.  Other 
solutions  which  may  be  used  under  the  same  circum- 
stances are  chlorine-water  andlysoform  in  weak  solution. 

The  author  has  recently  analyzed  the  after-history  in 
100  consecutive  cases  of  operation  for  appendicitis  in  one 
of  the  London  hospitals,  for  the  purpose  of  ascertaining 
the  percentage  of  complications  and  the  after-results  that 
may  follow  this  operation. 

In  this  series  the  mortality  was  8  per  cent. ;  of  these 
3  cases  died  from  meteorism  and  peritonitis,  2  from  other 
forms  of  sepsis,  2  from  bronchitis,  and  i  from  infarction 
of  the  lung. 

Complications,  including  several  cases  of  stitch  sup- 
puration, occurred  in  48  per  cent,  of  the  cases. 

In  4  per  cent,  the  patient  developed  a  secondary 
empyema  on  the  right  side,  and  in  i  per  cent,  a  right 
pleurisy.  Infarction  of  the  lung  occurred  in  5  per  cent, 
of  the  cases,  the  infarction  occurring  in  i  case  on  the  first 


Operations  on  the  Abdomen        207 

day,  in  2  cases  on  the  ninth  day,  in  i  case  on  the  tenth 
day,  and  in  i  case  on  the  twelfth  day ;  and  of  these  5  cases, 
thrombosis  in  the  lower  extremities  was  detected  in  3. 

Loculation  of  the  pus  with  recurrence  of  some  of 
the  symptoms,  and  necessitating  reopening  the  wound 
occurred  in  15  per  cent,  of  cases. 

A  faecal  fistula  formed  in  g  per  cent.  Meteorism 
occurred  as  a  complication  in  7  per  cent,  of  the  cases. 

The  percentage  of  complications  in  this  series  seems 
high,  but  this  is  accounted  for  by  the  fact  that,  as  in  all 
hospital  statistics,  many  cases  are  included  which  were 
in  a  desperate  state  when  operated  upon. 

These  statistics  were  made  in  1903,  and  would  not 
apply  to-day,  as  with  the  great  improvements  in  technique 
and  in  aseptic  methods  which  have  occurred  since  then, 
combined  with  the  fact  that  cases  of  acute  appendicitis 
are  now  operated  upon  much  earlier  than  was  then  the 
case,  complications  of  all  sorts  have  been  enoripously 
diminished,  so  that  the  mortality  is  now  less  than  i  per 
cent,  in  the  best  practices,  and  complications  generally 
correspondingly  less  frequent. 

A  certain  amount  of  trouble  may  be  experienced  in 
getting  the  bowels  to  act  for  the  first  few  weeks  after 
the  operation,  owing  to  the  formation  of  adhesions 
between  the  coils  of  intestine.  This  is  particularly 
liable  to  occur  if  the  abscess  has  tracted  down  into  the 
pelvis.  It  can,  however,  be  overcome  by  the  proper  use 
of  salts,  and  in  most  cases  the  adhesions  will  soon  stretch 
and  disappear. 

When  an  abscess  has  been  opened,  or  there  has  been 
much  inflammatory  mischief  around  the  appendix, 
adhesions  are  apt  to  form  in  the  neighbourhood  of  the 
wound,  and  as  time  elapses,  and  these  adhesions  contract, 
they  may  cause  a  considerable  amount  of  discomfort  and 


2o8     The  After-Treatment  of  Operations 

pain.  In  the  cases  analyzed  by  the  author,  symptoms 
which  appeared  to  be  caused  by  adhesions  were  present 
from  one  to  two  years  after  the  operation  in  i8  per  cent- 
(see  also  p.  192). 

The  different  complications  and  the  methods  of  dealing 
with  them  have  already  been  referred  to  in  the  previous 
chapter. 

Ventral  hernia  sometimes  follows  the  operation  for 
removal  of  the  appendix,  and  it  is  a  peculiar  fact  about 
these  herniae  that  they  are  often  very  painful.  When 
this  is  the  case,  a  further  operation  should  be  performed 
for  the  cure  of  the  hernia. 

Radical  Cure  of  Hernia. 

Special  Complications. — (i)  Epididymo  -  orchitis ; 
(2)  retention  of  urine ;  (3)  separation  of  the  deep  sutures ; 
(4)  persistent  vomiting  ;  (5)  recurrence. 

In  order  to  keep  the  dressings  dry  it  is  advisable,  in  the 
male,  to  place  a  piece  of  jaconet  with  a  hole  in  it  over 
the  dressings,  the  penis  being  made  to  emerge  through 
the  hole.  In  young  children  it  is  so  difficult  to  keep  the 
dressings  dry  that  it  is  advisable  to  apply  a  collodion 
dressing  to  the  wound  in  the  first  instance,  and  to  place 
a  large  pad  of  wool  over  this,  which  can  be  changed  con- 
stantly. The  best  way  of  nursing  quite  young  children 
after  operations  for  the  radical  cure  of  hernia  is  to  sling 
their  legs  up  to  a  cross-bar  over  the  bed,  in  the  same  way 
as  is  done  in  Bryant's  method  of  treating  fracture  of  the 
femur.  This  not  only  enables  the  small  patient  to  be 
kept  much  cleaner  than  would  otherwise  be  the  case,  but 
the  flexed  position  of  the  thigh  acts  as  a  protection  to  the 
inguinal  rings,  and  prevents  undue  pressure  being  exerted 
on  them,  during  the  period  of  healing  of  the  wound,  from 
crying,  etc. 


Operations  on   the  Abdomen        209 

Ihe  usual  time  during  which  the  patient  should  be 
kept  in  bed  after  these  operations  is  from  three  weeks  to 
a  month.  Three  weeks  is,  however,  all  that  is  usually 
necessary.  When  the  patient  is  first  allowed  to  get  up 
after  the  operation,  a  pad  of  wool  held  on  by  a  firm 
spica  bandage  should  be  applied  over  the  inguinal 
canal.  This  should  be  worn  for  the  first  week.  After 
that  all  support  to  the  canal  can  usually  be  dispensed 
with.  The  use  of  a  truss  after  the  radical  cure  of 
hernia  is  inadvisable,  as  the  continuous  pressure  exerted 
by  a  truss  tends  to  weaken  the  scar  and  surrounding 
tissues,  and  therefore  tends  towards  the  recurrence  of 
the  affection.  Of  course,  when  the  operation  has  been 
undertaken  for  the  purpose  of  enabling  the  patient  to 
wear  a  truss — that  is  to  say,  when,  owing  to  the  nature 
of  the  case,  a  real  radical  cure  of  the  condition  was  not 
to  be  expected,  and  the  operation  was  undertaken  with 
the  object  of  so  improving  the  local  conditions  as  to 
allow  of  a  truss  keeping  up  the  hernia  —  the  case  is 
different :  a  light  truss,  therefore,  should  be  ordered  in 
these  cases.  The  patient  after  the  operation  for  hernia 
should  be  warned  against  the  danger  of  lifting  heavy 
weights,  or  exerting  himself  in  any  way,  for  the.  first  two 
months  or  so  afterwards,  as  the  parts  are  not  thoroughly 
consolidated  for  that  time,  and  any  violent  exertion  is 
liable  to  cause  the  hernia  to  come  down  again. 

I.  Epididymo -orchitis. — It  is  not  at  all  uncommon  after 
operations  for  hernia  to  find  a  few  days  after  the  opera- 
tion that  there  is  some  swelling  and  tenderness  of  the 
epididymis  and  testicle  on  the  same  side.  This  is  most 
probably  due  to  the  interference  with  the  veins  of  the 
cord  at  the  time  of  the  operation,  or  to  the  cord  being 
constricted  by  the  ring  having  been  sewn  up  a  little  too 
tightly.  The  swelling  is  often  considerable,  but  it  is  of  no 

14. 


2 10    The   After-Treatment  of  Operations 

consequence,  and  all  subsides  in  the  course  of  a  day  or 
two.  If  there  is  much  pain  or  discomfort,  the  testicle 
should  be  supported  by  a  small  cushion  or  slung  up  well 
on  to  the  abdomen  by  means  of  a  bandage,  and  evapor- 
ating lotions  applied  to  relieve  the  pain.  Occasionally 
this  swelling  and  enlargement  of  the  testis,  etc.,  persists 
for  a  week  or  two,  but  invariably  subsides  without  any 
harm  resulting. 

2.  Retention  of  Urine. — This  is  not  uncommon  tor  the 
first  twenty-four  hours  after  the  operation.  Loosening 
the  bandages  is  sometimes  all  that  is  necessary  to  enable 
the  patient  to  pass  his  water.  If  simple  means  fail,  a 
catheter  should  be  passed  and  the  urine  drawn  off,  the 
usual  precautions  being,  of  course,  taken  to  prevent  the 
introduction  of  organisms  into  the  bladder. 

3.  Separation  of  the  Deep  Sutures. — This  has  already 
been  referred  to  under  the  head  of  '  Laparotomy.'  It 
is  a  particularly  annoying  complication  in  these  cases, 
as  it  may  render  the  operation  ineffectual. 

4.  Persistent  Vomiting. — Leaving  out  of  account  the 
vomiting  due  to  the  anaesthetic,  peritonitis,  or  meteorism, 
which  have  already  been  referred  to,  this  complication 
is  usually  seen  after  operations  for  the  cure  of  large 
scrotal  hernia  when  portions  of  the  omentum  have  been 
ligatured  and  cut  away.  The  vomiting  generally  comes 
on  about  a  week  or  ten  days  after  the  operation,  and  is 
accompanied  by  some  tenderness  of  the  abdomen  and 
symptoms  which  at  first  are  easily  mistaken  for  those  of 
peritonitis.  The  condition  is  either  due  to  some  sloughing 
of  the  omental  stump  or  to  the  formation  of  adhesions 
between  it  and  the  surrounding  coils  of  intestine.  The 
condition  is  not  common,  but  is  seen  occasionally ;  the 
symptoms  generally  pass  off  in  the  course  of  a  few  days, 
and  no  harm  results  to  the  patient.     The  patient  should 


Operations  on  the  Abdomen        2ii 

be  put  on  a  fluid  diet  again  if  solids  have  been  allowed, 
and  the  bowels  should  be  well  opened  with  saline 
aperients.  The  symptoms  usually  subside  after  the 
bowels  have  been  well  opened.  Pain  often  accompanies 
the  symptoms,  and  is  best  treated  by  hot  fomentations; 
and,  if  necessary,  by  the  use  of  morphia. 

5.  Recurrence.  —  The  question  of  recurrence  hardly 
comes  within  the  scope  of  this  work.  Fortunately,  with 
the  present  improved  methods  of  operating  it  is  not  very 
often  seen  now,  but  even  after  the  best  operations  cases 
will  occasionally  occur.  In  the  case  of  hospital  patients, 
many  of  whom  are  navvies,  whose  work  entails  the  lifting 
of  heavy  weights,  often  with  the  knees  bent,  and  who 
can  seldom  afiford  to  keep  away  from  their  work  for  a 
sufficient  time  after  the  operation  to  insure  the  best 
results  from  it,  it  is  not  surprising  that  recurrence  is 
sometimes  seen ;  indeed,  it  is  a  matter  of  surprise  that 
the  results  under  these  circumstances  are  as  good  as 
they  are. 

Operations  on  the  Kidney. 

Special  Complications. — (i)  Uraemia;  (2)  severe 
pain  ;  (3)  vomiting ;  (4)  high  temperature  ;  (5)  pulmonary 
embolism  ;  (6)  hgematuria ;  (7)  renal  colic. 

The  after-treatment  of  these  cases  is  practically  the 
same  as  for  laparotomy.  When  a  drain  has  been  placed 
in  the  loin,  frequent  changing  of  the  dressings  will  be 
necessary  to  keep  the  patient  dry,  and  if  there  is  a  ten- 
dency for  the  akin  round  the  wound  to  become  sore  from 
the  constant  irritation  of  the  discharge,  a  little  ointment 
should  be  smeared  over  the  skin  to  prevent  this.  After 
nephrectomy  everything  that  is  possible  should  be  done 
to  diminish  the  work  of  the  remaining  kidney  until  it  has 


212     The   After-Treattnent  of  Operations 

become  accustomed  to  the  new  conditions.  The  diet 
should  be  bland,  and  all  highly  nitrogenous  diets  are 
best  avoided,  as  they  will  give  the  kidney  more  work  to 
do  in  excreting  urea  than  would  less  nitrogenous  diets. 
Morphia  or  opium  in  any  form  is  best  avoided,  as  it  tends 
to  diminish  urinary  secretion.  The  skin  and  bowels 
should  be  kept  acting,  so  as  to  relieve  the  work  of  the 
remaining  kidney.  The  amount  of  urine  passed  per 
diem  should  be  measured  and  charted,  so  that  any 
diminution  in  the  quantity  may  be  noticed  at  once. 

1.  Uremia. — When  the  excretion  of  urine  diminishes 
and  uraemia  threatens,  the  case  should  be  treated  in  the 
same  way  as  for  an  ordinary  case  of  uraemia— that  is  to 
say,  the  skin  must  be  made  to  act  by  the  use  of  hot-air 
baths  or  pilocarpine,  and  the  bowels  must  be  kept  acting 
freely.  The  application  of  hot  fomentations  over  the 
healthy  kidney  is  often  useful. 

2.  Pom  does  not  always  occur,  but  may  be  very  severe. 
It  is  g^ierally  of  a  shooting  character,  running  dow^n 
into  the  groin  and  inner  side  of  the  thigh  on  the  same 
side.  Sir  William  Bennett  has  pointed  out  that  when 
this  pain  is  present  in  a  marked  degree  after  the  kidney 
has  been  stitched  into  the  loin  (nephrorrhaphy),  a  nerve 
has  probably  been  included  in  the  suture.  On  one  occa- 
sion, when  the  pain  was  especially  severe,  he  found  this 
to  be  the  case.  The  advisability  in  such  a  case  of  open- 
ing the  wound  and  dividing  the  suture  will  have  to  be 
considered. 

Slight  renal  colic  may  occur  after  some  operations  on 
the  kidney,  especially  nephrotomy,  and  is  due  to  the 
passage  of  blood-clots  down  the  ureter.  This  is  best 
treated  by  hot  fomentations,  etc.  Morphia  must  not  be 
given  if  there  is  any  uncertainty  as  to  the  condition  of 
the  other  kidney.    If,  however,  it  is  known  that  the  other 


Operations  on  the  Abdomen        2 1  3 

kidney  is  healthy,  and  there  has  been  no  diminution  in 
the  amount  of  urine  excreted  since  the  operation,  it  may 
be  given  with  safety. 

3.  Persistent  Vomiting  after  operations  on  the  kidney, 
and  especially  after  nephrorrhaphy,  sometimes  occurs, 
and  may  accompany  the  high  temperature  mentioned 
below.  It  is  probably  due  to  the  same  cause.  The 
patient  often  vomits  on  and  off  for  some  days ;  the  con- 
dition is  not,  as  a  rule,  serious.  It  is  as  well  to  remember 
the  possibility  of  this  complication  occurring  after  opera- 
tions on  the  kidney,  as  otherwise  the  symptoms  may  give 
rise  to  serious  fears  of  peritonitis. 

4.  High  Temperature. — A  high  temperature  is  not  at 
all  uncommon  after  the  kidney  has  been  much  inter- 
fered with.  After  nephrorrhaphy  a  high  temperature 
may  persist  for  a  week  or  longer,  the  temperature  often 
varying  from  100°  to  103°  F.  This  is  probably  due  to 
interference  with  the  sympathetic  nerves.  It  need  not 
give  rise  to  alarm,  and  it  is  not  accompanied  by  any 
inflammatory  condition.  The  temperature  rises  directly 
after  the  operation,  and  remains  up.  Should  the  tempera- 
ture, however,  be  normal  or  subnormal  for  the  first  few 
days  and  then  rise,  it  will  not  be  due  to  this  cause,  and 
sepsis  must  be  suspected  and  the  wound  examined, 
and,  if  necessary,  opened.  The  patient  may,  while  the 
temperature  persists,  feel  flushed  and  uncomfortable. 

5.  Pulmonary  Embolism. — This  is,  fortunately,  a  rare 
complication.     For  treatment,  see  Chapter  VII. 

6.  Hmnaturia.  —  This  not  infrequently  occurs  after 
operations  in  which  the  kidney  has  been  explored.  It 
is  due  to  oozing  from  the  kidney  substance,  and,  as  a 
rule,  stops  within  forty-eight  hours  of  the  operation.  If 
severe,  it  should  be  treated  by  an  ice-bag  applied  to  the 
loin,  and  calcium  chloride  by  the  mouth  or  rectum,  in 


214    The  After-Treatment  of  Operations 

large  doses.  It  should  never  be  treated  by  administer- 
ing adrenalin  or  ergot  internally,  as  these  drugs  raise  the 
general  blood-pressure  without  constricting  the  renal 
vessels,  and  so  tend  to  increase  the  haemorrhage. 

7.  Renal  Colic  — This  may  occur  after  nephrotomy. 
It  may  be  due  to — {a)  the  passage  of  a  blood-clot  down 
the  ureter;  {h)  a  portion  of  stone  which  has  become 
detached  from  the  main  stone  during  its  removal  from 
the  renal  pelvis,  or  even  to  a  small  stone  which  has  been 
overlooked  at  the  operation. 

The  best  treatment  under  such  circumstances  is  to 
relieve  the  pain  by  morphia  and  hot  stupes  to  the  loin 
and  abdomen,  and  at  the  same  time  to  give  the  patient 
plenty  of  fluid  to  drink  so  as  to  wash  out  the  clot  or 
fragment  in  the  ureter. 


CHAPTER  XV 
OPERATIONS  ON  THE  GENITO-URINARY  TRACT 

One  of  the  most  important  things  to  be  attended  to  in 
the  after-treatment  of  operations  on  the  genito-urinary 
tract  is  to  keep  the  patient  as  dry  as  possible.  There  is 
a  great  tendency  for  the  dressings  to  become  soaked  with 
urine,  and  if  such  dressings  remain  long  in  contact  with 
the  skin,  especially  of  old  men,  it  is  very  liable  to  get  raw 
and  inflamed.  And  quite  apart  from  this,  the  constant 
state  of  smell  and  dampness  which  the  patient  is  in 
cannot  but  cause  him  considerable  misery  and  discom- 
fort. To  prevent  this  the  dressings  should  be  frequently 
changed,  and  mackintosh  sheets  should  be  arranged  round 
the  ends  of  the  tubes,  etc.,  to  prevent,  as  far  as  possible, 
the  urine  getting  on  to  the  dressings.  It  is  well  to  keep 
the  skin  powdered  with  starch  or  boracic  powder. 

Most  wounds  resulting  from  operations  on  the  bladder 
or  urethra  are  left  open,  and  have  to  heal  by  granulation. 
Consequently  it  is  necessary  to  frequently  change  the 
dressings  and  to  keep  the  wound  clean  by  irrigation. 
These  cases  require  constant  attention  and  skilled 
nursing.  It  is  important  to  see  that  the  patient  has  a 
suitable  bed.  This  should  be  a  good  height,  as  a  low 
bed  is  a  great  inconvenience  ;  and  it  should  also  have  a 
mattress  which  does  not  form  a  hollow  in  the  middle. 

215 


2i6     The  After-Treatment  of  Operations 

A  pneumatic  ring-pillow  with  a  removable  linen  cover 
should  be  placed  under  the  patient's  sacrum. 

The  best  way  to  alleviate  pain  after  these  operations  is 
by  means  of  suppositories  of  morphia  and  belladonna, 
though  the  use  of  opium  in  any  form  is  best  avoided  in 
cases  where  the  kidneys  have  been  interfered  with  or 
where  they  are  thought  to  be  diseased.  The  bowels 
should  always  be  kept  acting  loosely  for  some  time  after 
the  operation.  One  of  the  most  important  things  to 
assure  success  in  these  operations  is  to  keep  the  urine 
sweet  and  to  prevent  acidity.  For  this  purpose  some 
drug  should  be  given  which  is  excreted  in  the  urine  as 
an  antiseptic.  Of  these  there  are  several,  Boracic  acid 
or  salol,  given  in  lo-grain  doses  three  times  daily,  may 
be  used,  or  urotropine,  in  5  to  10  grain  doses  in  an  ounce 
of  water,  three  times  daily  ;  free  diuresis  is  more  im- 
portant than  drugs,  and  to  secure  this  the  patient  should 
be  encouraged  to  drink  plenty  of  barley-water  or  other 
fluids.  Where  the  urine,  in  spite  of  these  precautions, 
remains  foul,  and  cystitis  is  present,  the  bladder  should 
be  washed  out  twice  a  day  with  some  mild  antiseptic, 
such  as  boracic  lotion. 

The  use  of  stronger  antiseptics  than  this  is  not 
advisable,  as  they  often  give  rise  to  a  considerable 
amount  of  pain,  and  are  liable  to  make  the  cystitis 
worse.  Where  the  cystitis  will  not  improve  with  this 
treatment,  solutions  of  protargol  or  argyrol  (|  to  i  per 
cent.)  may  be  used  with  advantage.  In  washing  out 
the  bladder,  only  2  or  3  ounces  of  fluid  must  be  injected 
at  a  time  and  allowed  to  run  out  again,  this  being  re- 
peated until  the  solution  comes  back  quite  clear.  The 
solution  should  be  at  a  temperature  of  about  100°  F. 
The  best  apparatus  for  washing  out  the  bladder  is  a  soft 
rubber  catheter  on  the  end  of  a  glass  funnel. 


Genito-Urinary  Tract  Operations    217 

When  the  urine  is  very  alkaline,  benzoate  of  ammonium 
can  be  combined  with  the  boric  acid  in  lo-grain  doses 
three  times  a  day  by  the  mouth,  or  urotropine  may  be 
used.  When  the  urine  is  very  acid,  bicarbonate  of  soda, 
in  10  or  20  grain  doses,  should  be  given  by  the  mouth, 
either  alone  or  combined  with  one  of  the  other  drugs 
mentioned  above  uritil  the  urine  is  rendered  neutral. 

Catheter  Fever.  —  After  any  operation  on  the 
urethral  tract,  or  after  the  passage  of  instruments,  etc., 
the  so-called  condition  of  catheter  or  urethral  fever  is 
liable  to  occur.  It  usually  comes  on  during  the  first 
thirty-six  hours,  though  it  sometimes  occurs  after  the 
removal  of  an  instrument  that  has  been  tied  in  at  the 
operation,  and  it  is  well  to  be  on  the  look-out  for  this. 
It  often  follows  the  first  act  of  micturition  after  the 
operation.  The  patient  shivers,  and  has  a  rigor,  followed 
by  a  hot  stage  and  profuse  sweating ;  this  condi- 
tion soon  passes  off  in  the  majority  of  cases,  and 
is  not  dangerous  unless  followed  by  suppression  of 
urine,  which  is  very  rarely  seen,  and  practically  only 
occurs  when  the  kidneys  are  diseased — 10  grains  of 
Dover's  powder,  administered  before  the  operation, 
will  usually  prevent  the  occurrence  of  these  unpleasant 
symptoms.  If  a  large  catheter  has  been  tied  in  after 
the  operation,  the  same  powder,  given  that  night, 
will  often  facilitate  its  removal  next  day,  and  add  to 
the  comfort  of  the  patient ;  or  an  excellent  plan  is  to 
remove  the  instrument  while  the  patient  is  sitting  in  a 
hot  bath.  This  is  a  good  plan  whenever  large  instru- 
ments have  to  be  passed  or  withdrawn  from  irritable 
urethras.  In  order  to  prevent  the  occurrence  of  this 
complication  after  operations  on  the  urethral  tract, 
Mr.  Freyer*  recommends  that  a  draught  containing 
*  'Operations  on  the  Urethra  and  Prostate,' 


2 1  8     The  After-Treatment  of  Operations 

quinine  (5  grains)  and  liquor  opii  sedativus  (15  minims) 
should  be  administered  on  recovery  from  the  anaesthetic, 
and  quinine  (10  grains)  given  daily  for  two  or  three  days 
afterwards. 

Occasionally  a  much  more  severe  condition  of  this 
fever  is  seen.  There  are  repeated  attacks  of  fever, 
accompanied  by  high  temperature  and  rigors,  or  the  fever 
is  more  or  less  sustained,  and  the  patient  gradually  sinks 
into  a  low  state,  with  feeble  pulse,  etc.  This  is  more 
common  in  old  patients  and  those  who  have  had  a 
cystitis  previous  to  the  operation,  or  some  other  septic 
focus  in  or  near  the  field  of  operation.  The  condition  is 
probably  a  septic  one,  and  must  be  treated  on  those 
lines.  The  great  danger  is  suppression  of  urine  and 
uraemia.  When  this  occurs,  it  must  be  treated  by 
purgation  and  sweating,  and,  of  course^  opium  in  any 
form  must  be  absolutely  avoided. 

The  best  way  of  treating  this  severe  type  of  urinary 
fever  is  by  preventing  its  occurrence,  and  it  ought  to  be 
very  rare  if  proper  care  is  taken.  Unfortunately,  the 
whole  genito-urinary  tract  is  in  a  septic  condition  in 
some  of  these  cases,  especially  when  dealing  with  old 
and  neglected  prostatic  trouble,  and  it  is  in  such  cases 
that  it  is  most  commonly  seen. 

Diet. — The  main  object  in  dieting  is  to  keep  the 
urine  neutral  and  prevent  acidity ;  therefore  it  is  well  to 
avoid  nitrogenous  foods  as  far  as  possible,  and  starchy 
foods  should  be  given.  For  the  first  few  days  after  the 
operation  the  diet  should  be  a  light  one,  and  plenty  of 
fluids  may  be  allowed  with  advantage,  as  this  helps  to 
wash  out  the  genito-urinary  tract.  In  old  and  debilitated 
subjects  it  is  so  important  to  keep  up  their  strength  that 
a  low  diet  is  not  advisable,  and  it  should  be  sustaining 
from  the  first,  and  combined  with  stimulants  of  a 
suitable  nature, 


Genito-Urinary  Tract  Operations     219 

Suprapubic  Cystotomy. 

COMPLICATION'S. — (i)  Severe  cystitis ;  (2)  pelvic  cellu- 
litis ;  (3)  suppression  of  urine ;  (4)  epididymitis. 

For  the  first  twenty-four  or  forty-eight  hours  the 
wound  is  best  dressed  with  absorbent  dressings,  which 
must  be  changed  as  soon  as  they  become  soaked  with 
urine.  It  is  important  to  remember  that  because  the 
wound  is  open  and  primary  union  is  not  aimed  at,  the 


Fig.  33. 


necessity  for  careful  aseptic  precautions  in  changing  the 
dressings  is  not  lessened,  but,  on  the  other  hand,  is 
greater.  The  surgeon  should,  when  possible,  see  to  the 
dressings  himself,  or,  at  least,  see  that  someone  who 
thoroughly  understands  aseptic  technique  does  so  for 
him. 

After  the  first  twenty-four  or  forty-eight  hours  the  best 
plan  is  to  apply  some  form  of  apparatus  which  will  drain 


220    The  After-Treatment  of  Operations 

away  the  urine  and  prevent  it  from  accumulating  in  the 
dressings.  There  are  several  forms  of  apparatus  for  this 
purpose ;  the  best,  however,  appears  to  be  that  devised 
by  Mr.  Hamilton  Irving  (see  Fig.  33  ).  This  apparatus 
consists  of  a  celluloid  cap  which  fits  over  the  w^ound, 
and  is  retained  in  place  by  straps  passing  round  the 
body.  From  this  cap  there  are  two  outlet  pipes  com- 
municating either  with  a  urinal  between  the  patient's 
thighs  or  with  a  receptacle  at  the  side  of  the  bed.  There 
is  a  removable  lid  to  the  cap  which  allows  the  wound  to 
be  examined  or  the  bladder  irrigated  without  removing 
the  apparatus.  It  also  enables  continuous  irrigation  of 
the  bladder  to  be  very  easily  arranged  for.  When  this 
apparatus  is  used  no  dressings  are  required,  and  all  that 
is  necessary  is  to  see  that  it  is  kept  clean. 

When  such  an  apparatus  is  not  available  the  dressings 
must  be  frequently  changed,  so  as  to  keep  the  patient 
as  dry  as  possible  ;  but  after  the  first  forty-eight  hours 
plain  sterilized  dressings  should  alone  be  used,  as  medi- 
cated dressings  soon  cause  soreness  and  vesication  of  the 
skin. 

The  drainage-tube  should  be  removed  at  the  end  of 
twenty-four  or  forty-eight  hours,  and  many  surgeons  tie 
a  large  catheter  into  the  urethra,  so  as  to  allow  the  urine 
a  free  escape  by  the  normal  channel. 

The  time  which  it  takes  for  the  suprapubic  opening 
to  close  varies  from  about  twelve  days  to  three  or  four 
weeks,  and  even  longer  in  some  cases.  The  patient  should 
be  kept  in  the  recumbent  position,  and  not  allowed  to 
stand  up  for  a  week  after  the  suprapubic  wound  has 
healed  up,  as  otherwise  there  is  some  risk  of  its  opening 
again.  Care  should  also  be  taken  to  prevent  the  bladder 
becoming  distended. 

If  there  is  much  cystitis  and  the  urine  is  very  foul, 


Genito-Urinary  Tract  Operations     221 

continuous  irrigation  of  the  bladder  with  warm  Avater 
Fhould  be  arranged  for,  and  urotropine  given  by  the 
mouth  in  full  doses. 

Suppression  of  urine  has  been  already  mentioned 
under  catheter  fever.  It  is  a  condition  calling  for 
prompt  treatment.  The  main  indications  are  to  relieve 
as  far  as  possible  the  congestion  of  the  renal  tissues  by 
leeches  to  the  loin,  and  purgation,  and  at  the  same  time 
to  encourage  the  excretion  of  the  urea,  etc.,  by  the  skin 
and  bowel,  so  as  to  tide  the  patient  over  the  dangerous 
period  while  the  kidneys  are  not  acting. 

Hot  antiseptic  baths  of  boracic  or  very  weak  per- 
chloride  are  a  good  way  of  dealing  with  complications 
occurring  after  operations  on  the  urinary  tract  when  the 
patients  are  strong  enough  to  stand  them;  but  they  are 
sometimes  dangerous  in  old  people,  and  in  any  case  a 
competent  attendant  must  be  present. 

Prostatectomy. 

Complications. — (i)  Haemorrhage;  (2)  epididymitis; 
(3)  incontinence  ;  (4)  uraemia; 

In  the  suprapubic  operation  the  treatment  of  the 
wound  is  practically  the  same  as  in  an  ordinary  supra- 
pubic cystotomy.  It  is  the  practice  of  most  surgeons  to 
administer  urotropine  or  urotropine  and  water  freely  for 
some  days  previous  to  and  after  the  operation.  This  is 
advisable,  as  it  tends — at  any  rate,  to  some  extent — to 
asepticize  the  genito-urinary  tract. 

The  bladder  should  be  irrigated  twice  daily  after  the 
operation,  and  if  there  is  much  sepsis  continuous  irriga- 
tion should  be  arranged  for.  It  is  important,  however, 
to  avoid  any  distension  of  the  bladder,  especially  during 
the  first  two  days,  as  it  might  cause  haemorrhage.  Any 
clots  which  are  found  to  have  formed  in  the  bladder 


2  22     The  After-Treatment  of  Operations 

must  be  carefully  removed.  The  irrigation  should  either 
be  done  with  sterilized  water  or  with  some  weak  anti- 
septic solution,  such  as  i  in  5,000  potassium  per- 
manganate. 

Irrigation  shouid  be  stopped  as  soon  as  the  patient 
commences  to  pass  urine  freely  per  urethram. 

Haemorrhage  should  be  treated  by  irrigation  with 
hazeline  or  silver  nitrate  solution  (i  in  5,000)  as  hot  as 
can  be  borne  (110°  to  120°  F.).  The  foot  of  the  bed 
should  be  well  raised.  If  this  fails  to  control  the  bleeding, 
an  anaesthetic  must  be  administered,  and  the  bladder 
firmly  packed  with  long  strips  of  gauze,  the  ends  pf 
which  are  left  projecting  out  of  the  wound;  the  gauze 
should  be  removed  in  twenty-four  hours. 

Incontinence  or  dribbling  away  of  the  urine  may  occur, 
and  is  a  very  unpleasant  complication ;  it  is  due  to  ex- 
cessive injury  to  the  neck  of  the  bladder,  and  destruction 
of  the  sphincter  vesicae. 

In  the  perineal  operation  the  tube  is  generally  removed 
inside  a  week  from  the  operation,  and  the  wound  should 
be  closed  in  three  weeks. 

Lithotrity. 

Complications. — These  are  the  same  as  for  cystotomy, 
but  there  is  a  greater  liability  to  urinary  fever  and  epidi- 
dymitis. The  patient  should  be  kept  in  bed  for  a  week 
or  ten  days ;  a  large  catheter  should  be  tied  into  the 
bladder  for  the  first  thirty-six  hours.  He  should  be 
instructed  to  turn  on  to  the  side  to  pass  water.  Hot 
fomentations  to  the  abdomen  are  very  comforting  to  the 
patient  during  the  first  twenty-four  hours,  and  morphia 
or  some  opium  preparation  may  be  administered  if  there 
is  pain.  The  patient  should  be  allowed  to  sit  in  a  hot 
hip-bath  for  fifteen  or  twenty  minutes  two  or  three  times 


Genitd-Urinary  Tract  Operations     223 

a  day,  and  instructed  to  try  and  pass  his  water  while  in  the 
bath.  It  is  sometimes  necessary  to  draw  off  the  urine 
by  means  of  a  catheter  for  the  first  few  days.  Quinine 
or  salicylate  of  soda  may  be  administered  by  the  mouth, 
and  will  do  much  to  prevent  the  occurrence  of  fever. 
Morphia  suppositories  are  very  useful  in  relieving  pain 
after  the  operation.  The  diet  for  the  first  few  days 
should  consist  of  milk,  barley-water,  and  be  combined 
with  stimulants,  if  necessary.  Mr.  Jacobson  says :  *  '  It 
is  advisable  to  once  more  thoroughly  wash  out  the 
bladder  with  the  evacuator  a  week  after  the  operation,  as 
a  safeguard  against  recurrence  from  small  fragments  left 
behind  at  the  operation. 

Internal  Urethpotomy. 

Complications. — (i)  Haemorrhage;  (2)  urinary  fever ; 
(3)  epididymitis. 

Haemorrhage,  should  it  occur,  is  best  treated  by  tying 
in  a  catheter  ;  if  this  proves  insufficient  a  perineal  bandage 
should  be  applied  with  a  suitable  pad  so  as  to  compress 
the  bulb  of  the  penis  against  the  catheter.  Many 
surgeons  tie  in  a  large  catheter  after  the  operation,  and 
leave  it  in  for  twenty-four  hours  ;  if  this  has  been  done 
it  should  be  removed  in  a  hot  bath,  and  a  large  instru- 
ment, preferably  a  steel  sound,  passed  every  two  days 
at  first,  and  at  the  end  of  ten  days  or  a  fortnight  the 
patient  may  be  taught  to  pass  it  for  himself,  and  told  to 
do  so  once  a  week  at  first,  and  later  at  more  distant 
intervals  for  some  months  to  prevent  recontraction  of  the 
scar  in  the  urethra.  Some  surgeons,  on  the  other  hand, 
prefer  not  to  pass  any  instrument  till  after  the  wOund  has 
healed,  which  will  be  in  about  ten  days  or  a  fortnight, 
and  then  to  pass  steel  dilators  (Mr.  Freyer  recommends 
*  '  The  Operations  of  Surgery,'  1903  edit.,  vol.  ii. 


2  24    The  After-Treatment  of  Operations 

Nos.  13  to  15  English  gauge)  so  as  to  insure  the  urethra 
being  well  dilated,  and  then  to  let  the  patient  pass  the 
instrument  for  himself  at  intervals  for  some  months 
afterwards. 

External  Urethrotomy. 

Complications. — (i)  Pelvic  cellulitis  and  peritonitis ; 
(2)  toxaemia ;  (3)  sloughing  of  the  rectum  ;  (4)  epididy- 
mitis. 

If  a  catheter  has  been  tied  in  at  the  operation  this 
should  on  no  account  be  removed  for  two  or  three  days, 
as  it  will  be  difficult  and  may  be  impossible  to  replace  it. 

If  a  perineal  tube  has  been  tied  in  it  should  be  retained 
for  four  or  five  days  and  then  removed.  At  the  end  of  a 
week  or  ten  days  a  steel  sound  should  be  passed  along 
the  urethra  into  the  bladder,  and  this  should  be  repeated 
every  second  or  third  day  till  the  perineal  wound  has 
healed. 

Circumcision. 

The  dressing  is  usually  a  matter  of  some  difficulty  in 
these  cases,  as  it  is  difficult  to  get  it  to  keep  on,  and  it 
easily  becomes  soiled.  Dry  gauze  and  collodion  makes 
an  excellent  dressing  if  the  wound  heals  aseptically,  but 
is  extremely  troublesome  to  remove,  and  sometimes 
causes  pain  ;  it  is  also  very  painful  if  erections  occur.  A 
very  good  way  of  dressing  these  cases  is  to  wrap  a 
narrow  piece  of  dry  cyanide  gauze  round  the  penis  at  the 
site  of  the  wound,  and  then  to  put  a  larger  strip  over  the 
top  of  this  and  overlapping  it.  A  pad  of  absorbent  wool 
about  2  inches  thick  and  large  enough  to  cover  the 
whole  perineum  and  come  well  up  into  the  abdomen  is 
next  taken,  and  a  hole  is  made  in  it  with  scissors  just 
large  enough  to  admit  the  penis ;  the  penis  is  placed  in 


Geni to-Urinary  Tract  Operations     225 

this  hole,  and  then  the  pad  of  wool  fixed  on  by  taking 
two  or  three  turns  of  bandage  round  the  body  and  thighs. 
This  protects  the  penis,  and  adds  very  materially  to  the 
patient's  comfort. 

In  hospital  practice  a  very  good  dressing  is  made  with 
strips  of  lint  soaked  in  lotio  plumbi  (diluted  one  half) 
wrapped  round  the  penis,  and  secured  to  the  abdomen  by 
a  strip  of  plaster.  The  mother  is  given  some  of  the 
lotion  and  instructed  to  keep  the  lint  moist  with  it, 
or  carbolic  oil  may  be  used  in  the  same  way.  The 
patient  should  be  kept  in  bed  for  the  first  forty-eight 
hours,  and  on  the  day  after  the  operation  he  should  sit 
in  a  warm  bath  and  soak  off  the  dressings,  a  new  dressing 
being  applied  afterwards  ;  this  should  be  repeated  each 
day  till  the  wound  has  healed.  After  the  first  two  or 
three  days  an  ointment  dressing  is  the  most  comfortable. 
If  there  is  much  swelling  and  oedema  after  the  operation, 
the  bath  should  be  used  twice  daily  and  weak  lead  lotion 
applied. 

After  operations  on  adults  it  is  advisable  to  administer 
a  dose  of  bromides  at  night  for  the  first  few  days  to 
prevent  erections.  The  patient  should  keep  his  bed  for 
the  first  two  days,  and  remain  resting  on  a  sofa  for  a 
week,  and  when  he  first  begins  to  get  about  should  keep 
a  large  pad  of  wool  round  the  penis  to  prevent  its  being 
knocked,  etc.  If  catgut  sutures  have  been  used  they 
may  be  left  to  come  away  of  themselves,  otherwise  the 
stitches  should  be  removed  one  or  two  at  a  time. 


Radical  Cure  of  Hydrocele. 

The  drainage-tube  should  be  removed  in  twenty- four 
hours,  and  the  wound  sealed  up  with  collodion.  Pressure 
should  be  maintained  by  means  of  wool  and  bandaging 
over  the  wound  so  as  to  prevent  the  collection  of  blood 


226     The   After-Treatment  of  Operations 

or  serum  in  the  scrotum,  and  to  promote  rapid  healing  by 
keeping  the  sides  of  the  wound  cavity  in  contact.  Care 
must  be  taken  to  keep  the  scrotum  well  up  on  to  the 
pubes ;  this  prevents  oedema  of  the  scrotum  and  pain,  and 
assists  to  keep  the  dressings  clean.  For  this  purpose  the 
best  thing  is  a  small  cushion  placed  between  the  legs  so 
as  to  support  the  scrotum,  or  a  suspensory  bandage  made 
of  gauze  and  pulled  up  firmly  is  an  excellent  plan. 
Some  of  the  stitches  may  be  removed  on  the  fourth  day, 
and  the  remainder  a  few  days  later ;  the  patient  should 
remain  in  bed  for  ten  days  or  a  fortnight,  and  should 
wear  a  suspensory  bandage  for  some  months. 

Varicocele. 

The  treatment  is  the  same  as  for  the  above,  but  no 
drainage  being  necessary,  the  wound  should  not  be 
examined  for  five  or  six  days,  when  the  stitches  may  be 
removed.  The  patient  may  be  allowed  to  get  up  in  a 
week  or  ten  days.  A  suspensory  bandage  should  be 
worn  for  two  or  three  months  after  the  operation. 

Operations  on  the  Uterus  or  Appendag-es. 

Retention  of  urine  is  common  after  any  operation  on 
the  uterus  or  pelvis,  and  the  greatest  care  must  be  exer- 
cised in  relieving  it  by  the  catheter,  as  cystitis  is  readily 
set  up  and  seriously  complicates  the  after-treatment ;  the 
most  careful  aseptic  precautions  should  be  taken  in  using 
the  catheter,  and  it  should  always  be  passed  by  sight 
and  not  under  the  clothes.  The  catheter  should  be 
passed  frequently — every  five  or  six  hours — to  prevent 
the  bladder  from  becoming  distended,  as  this  will  result 
in  much  discomfort  to  the  patient.  An  attempt  should 
be  made  to  get  the  patient  to  pass  her  water  while  lying 


Genito-Urinary  Tract  Operations     227 

on  the  side.  As  already  stated  many  women  are  unable 
to  pass  their  urine  while  in  the  dorsal  recumbent  position, 
and  in  consequence  there  is  apt  to  be  a  collection  of 
residual  urine  in  the  bladder  even  when  the  catheter  is 
in  use. 

The  vagina  must  be  kept  as  clean  and  aseptic  as 
possible  after  the  operation.  This  is  best  done  by  daily 
gentle  irrigation  with  some  mild  antiseptic  solution.  A 
pad  of  cyanide  gauze  well  dusted  over  with  some  anti- 
septic powder  should  be  kept  over  the  vulva  and  changed 
twice  a  day. 

After  many  operations  on  the  uterus,  and  especially 
those  in  which  retaining  stitches  are  placed  in  the  uterine 
wall,  there  is  very  severe  pain  for  some  days  after  the 
operation.  This  pain  can  often  be  relieved  by  such 
drugs  as  phenalgin  and  aspirin,  in  full  doses,  repeated 
every  four  or  five  hours.  Menstruation  often  comes  on, 
although  not  due,  after  such  operations,  and  may  be 
irregular  for  some  time  afterwards. 


CHAPTER   XVI 
OPERATIONS   ON   THE  RECTUM,  AND  COLOTOMY 

Operations  for  Fistula. 

Complications. — (i)  Formation  of  fresh  sinuses;  (2) 
bridging  of  the  wound ;  (3)  excessive  tenderness  of 
wound  ;  (4)  exuberant  granulations  ;  (5)  wound  refusing 
to  heal. 

In  my  opinion  no  surgeon  should  undertake  an  opera- 
tion for  fistula  unless  he  is  able  and  willing  to  supervise 
the  after-treatment  himself.  Too  often  the  surgeon 
operates  upon  a  case  of  fistula,  and  then  never  sees  the 
case  again,  or  not  until  the  wound  has  refused  to  heal. 
Most  of  the  failures  to  heal  in  the  case  of  fistula  are  due 
to  the  fact  that  those  responsible  for  the  after-treatment 
of  the  case  do  not  understand  what  is  necessary.  In 
proof  of  this,  the  fact  may  be  stated  that  the  average 
period  before  healing  is  complete  after  an  operation  for 
fistula  at  St.  Mark's  Hospital  is  under  four  weeks,  in 
spite  of  the  fact  that  probably  the  practice  of  this  hospital 
includes  most  of  the  worst  cases  of  fistula  in  London. 
The  actual  figures  for  over  200  of  the  author's  own  cases 
at  St.  Mark's  are  as  follows :  Average  period  of  healing 
in  days — males,  25-1  ;  females,  177.  Judging  from  the 
inquiries  the  writer  has  made,  the  average  period  before 

22S 


Operations  on   the  Rectum  229 

healing  is  complete  after  a  fistula  operation  at  some  of 
the  large  general  hospitals  is  nearer  two  and  a  half 
months. 

It  is  most  important  that  the  wound  should  be  kept  as 
clean  as  possible,  and  to  insure  this  the  dressing  should 
be  changed  frequently.  In  the  case  of  a  large  fistula 
wound  where  there  is  much  discharge,  the  dressing 
should  be  changed  every  six  hours,  or  even  oftener ;  and 
in  the  case  of  an  ordinary  fistula  wound  which  is  clean, 
it  should  be  changed  at  least  twice  a  day.  It  is  never 
sufficient  to  dress  the  wound  only  once  in  twenty-four 
hours,  or,  as  is  sometimes  the  practice  adopted,  once 
every  two  or  three  days.  For  the  first  three  or  four  days 
the  wound  should  be  dressed  with  hot  fomentations, 
changed  as  frequently  as  possible.  The  fomentations 
should  be  applied  over  the  wool  which  is  in  the  wound, 
and  the  latter  should  be  left  in  situ  for  the  first  thirty- 
six  hours,  and  then  changed  as  soon  as  it  is  soiled.  The 
bowels  should  be  opened  on  the  third  or  fourth  day  by  an 
aperient  dose,  aided  by  a  small  quantity  of  olive-oil 
injected  into  the  bowel.  After  this,  the  patient  should 
be  allowed  to  sit  in  a  hot  antiseptic  bath  night  and 
morning.  The  cotton-wool  will  soak  out  of  the  wound 
while  he  is  in  the  bath,  and  fresh  wool  should  be  carefully 
laid  in  the  wound  after  the  bath.  The  wound  is  best 
dressed  with  flat  strips  of  wool,  which  should  be  of  the 
best  quality,  and  not  the  cheap  fluff  so  often  supplied  in 
these  days.  A  narrow,  thin  strip  of  wool  should  be 
wrapped  around  a  dressing-probe,  and  by  means  of  the 
probe,  passed  up  into  the  deeper  part  of  the  wound  until 
it  enters  the  lumen  of  the  bowel.  If  the  probe  is  then 
gently  pressed  against  the  wound  it  can  be  removed, 
leaving  the  wool  in  position  in  the  wound.  The  first 
finger  of  the  left  hand  passed  into  the  bowel  will  often 


230    The  After-Treatment  of  Operations 

assist  in  placing  the  wool  accurately  in  position.  With 
the  end  of  the  probe  the  strip  of  wool  should  next  be 
adjusted  carefully  so  that  it  lies  evenly  along  the  floor  of 
the  wound.  Then  a  few  small  flat  strips  of  wool  should 
be  laid  in  any  side-tracks  or  superficial  portions  of  the 
wound.  On  no  account  should  the  wound  be  firmly 
plugged  with  dressing.  Plugging  of  the  wound  is  a  mis- 
take ;  in  fact,  there  is  no  more  effectual  method  of  pre- 
venting healing. 

When  once  the  surface  of  the  wound  is  covered  with 
healthy  granulations  it  is  important  to  protect  these  and 
the  growing  edge  of  the  skin  from  damage  each  time  that 
the  dressing  is  changed,  and  for  this  purpose  there  is 
nothing  better  than  a  dressing  of  wool  soaked  in  olive-oil 
or  vaseline.  At  this  stage  antiseptics  should  be  avoided, 
as  they  tend  to  damage  the  delicate  granulations  and  to 
delay  healing.  Peroxide  of  hydrogen,  though  useful  as  an 
application  to  clean  up  a  sloughy  wound,  should  not  be 
used  once  the  wound  has  cleaned  up,  as  it  tends  to 
produce  exuberant  and  unhealthy  granulations.  The 
wound  always  requires  careful  watchmg  to  see  that  heal- 
ing is  progressing  satisfactorily.  Occasional  stimulation 
is  often  required.  For  this  purpose  lotiod  rubra  applied 
on  wool  for  a  day  or  two,  or  Friar's  balsam  applied  once, 
is  very  useful.  Weak  silver  nitrate,  10  grains  to  the 
ounce,  may  sometimes  be  used  with  advantage,  but 
strong  silver  nitrate  should  not  be  used  except  to  destroy 
unhealthy  granulations,  as  it  usually  does  more  harm 
than  good.  Scarlet  red  ointment  is  sometimes  useful ; 
but  it  is  a  mistake  to  use  stimulating  applications  fre- 
quently. The  wound  must  be  carefully  watched  for  signs 
of  bridging  or  the  formation  of  new  tracks.  The  latter 
may  always  be  suspected  if  the  discharge  from  the  wound 
increases  in  amount  or  fails  to  stop.       If  a  previously 


Operations  on   the   Rectum  231 

healthy  wound  suddenly  begins  to  discharge,  it  is  an 
almost  certain  sign  that  a  new  track  has  formed.  Any 
bridges  of  tissue  that  are  discovered  should  be  broken 
down  with  a  steel  probe  or  cut  through  with  scissors,  and 
new  tracks  must  be  at  once  laid  open.  When  the  wound 
is  quite  healthy  and  nearly  healed  it  is  best  to  apply  no 
dressing  at  all,  but  to  keep  the  parts  clean,  and  apply  a 
little  vaseline  to  protect  the  surface. 

The  patient  should  be  kept  in  bed,  or  at  least  in  the 
recumbent  position,  until  healing  is  quite  complete  ;  and 
in  order  that  the  scar  may  become  firm  before  it  is 
subjected  to  much  movement,  he  should  not  walk  about 
more  than  is  absolutely  necessary  for  another  week  after 
this.  It  is  a  great  temptation  to  both  doctor  and  patient 
to  allow  the  latter  to  get  about  a  little  when  the  wound 
is  nearly  healed  ;  but  this  wastes  time  in  the  long  run, 
and  is  often  responsible  for  considerable  delay  in  the  final 
healing  of  the  wound. 

During  the  whole  process  of  healing  care  must  be 
taken  to  insure  that  the  stools  are  quite  soft,  as  a  hard 
stool  may  delay  healing  for  a  week  or  more. 

Causes  for  Non-Healing  of  the  Wound  after  an 
Operation  for  Fistula. — (i)  Inadequate  operation ; 
(2)  insufficient  drainage ;  (3)  too  tight  plugging  of  the 
wound  ;  (4)  bridging  of  the  wound ;  (5)  some  constitu- 
tional condition  of  the  patient. 

The  Operation  for  Piles. 

Complications. — (i)  Pain  ;  (2)  haemorrhage  ;  (3)  ul- 
ceration ;  (4)  stricture  ;  (5)  retention  of  urine  ;  (6)  for- 
mation of  external  piles  ;   (7)  fistula  or  fissure. 

The  dressing  should  be  changed  twice  a  day,  and  the 
external  parts  washed  with  weak  carbolic  lotion,  If  a 
tube  has  been  inserted  it  should  be  removed  in  twenty- 


2^2     The  Afcer-Treatment  of  Operations 

four  hours.  There  is  no  advantage  in  keeping  the  patient 
on  a  '  slop '  diet.  It  is  better  to  give  ordinary  food  in 
small  quantities  until  the  bowels  are  opened,  and  after 
this  a  full  ordinary  diet.  The  patient  may  be  allowed  to 
move  about  freely  in  bed,  so  long  as  he  does  not  disturb 
the  bandages.  The  bowels  are  confined  for  two  or  three 
days,  and  are  then  relieved  by  the  administration  of  an 
ounce  of  castor-oil,  or  some  other  suitable  aperient,  an 
injection  of  three  or  four  ounces  of  olive-oil  being  made 
into  the  bowel  with  a  soft  catheter  and  funnel  at  the 
same  time  that  the  aperient  is  administered.  As  an 
alternative  to  an  aperient,  the  bowels  may  be  relieved  by 
an  enema  of  olive-oil,  6  ounces,  and  thin  gruel,  14  ounces. 
The  bowels  should  subsequently  be  kept  acting  daily 
with  some  mild  aperient  such  as  cascara  or  petroleum. 
In  ordinary  cases  the  patient  may  safely  be  allowed  to 
use  a  night  commode  placed  beside  the  bed.  The  patient 
should  remain  in  bed,  or  at  any  rate  in  the  recumbent 
position,  until  the  ligatures  have  separated,  which  is 
somewhere  between  the  eighth  and  eleventh  days.  After 
this  he  should  be  kept  on  the  sofa  for  a  day  or  two 
longer. 

Operations  for  piles  have  in  the  past  had  a  very  bad 
name  for  causing  a  great  deal  of  pain.  All  operatons 
for  piles  used  to  be  accompanied  by  considerable  pain, 
and  it  was  the  custom  to  give  morphia,  or  some  other 
form  of  opium,  for  days  after  the  operation.  It  is,  how- 
ever, now  possible  to  prevent  this  pain  if  the  operation 
is  properly  performed,  and  if  the  after-treatment  is 
thoroughly  carried  outj  and  the  operation  for  piles  should 
result  in  no  more  pain  than  one  for  hernia  or  varicose 
veins.  The  pain  after  an  operation  for  piles,  as,  indeed, 
after  most  operations,  is  due  to  swelling  of  the  tissues 
and  inflammation  of  the  wound.  If,  after  the  removal  of 
the  piles,  the  wound  is  kept  clean  and  the  tissues  aseptic 


operations  on   the   Rectum  233 

for  some  hours,  there  is  no  severe  pain.  It  is  obvi- 
ously impossible  to  keep  the  wound  clean  for  a  long 
period.  In  order  to  keep  it  aseptic  for  a  few  hours  after 
the  operation  it  is  necessary  that  the  patient  shall  be  so 
prepared  for  operation  that  one  can  be  certain  no  faecal 
material  shall  be  found  in  the, rectum,  or  come  into  the 
area  of  operation,  either  during  or  immediately  after  the 
operation.  By  careful  attention  to  details  this  can  be 
insured.  The  author  has  found  by  experience  that  if 
great  care  is  taken,  when  operating  upon  piles,  to  make 
the  wounds  through  clean  tissues  and  to  keep  the  wounds 
clean  for  some  hours  afterwards,  pain  is  not  present  in 
any  marked  degree  in  the  majority  of  cases. 

Should  the  patient  complain  of  pain,  10  grains  of 
aspirin  every  six  hours  will  often  relieve  it.  If  the  pain 
is  severe,  l  grain  of  morphia  should  be  administered 
hypodermically.  Suppositories  containing  morphia  or 
other  drugs  should  not  be  used,  as  they  are  not  aseptic 
and  they  act  very  slowly. 

For  the  treatment  of  haemorrhage  after  this  operation, 
sec  p.  6g.  It  is  important  to  remember  that  when 
haemorrhage  occurs  after  an  operation  for  piles,  there  is 
seldom  any  external  evidence  of  its  presence,  as  unless  a 
tube  has  been  inserted,  the  blood  does  not  escape  from 
the  anus.  Should  a  patient  after  such  an  operation 
become  blanched  and  collapsed,  the  anus  should  at  once 
be  examined,  and  a  finger  passed  into  the  rectum  to 
ascertain  if  there  is  any  bleeding.  If  ligatures  have  been 
used,  they  generally  separate  between  the  eighth  and 
twelfth  days,  the  average  being  the  tenth  day.  The 
patient  should  not  be  allowed  to  get  up  until  all  the 
ligatures  have  come  away  ;  he  may  then  be  allowed 
to  recline  on  a  couch  or  easy-chair,  but  should  be 
more    or    less    restricted     to    the    horizontal    position 


2  34    The  After-Treatment  of  Operations 

until  on  examination  all  the  wounds  are  found  to  have 
healed. 

Ulceration  of  the  rectum  after  an  operation  for  piles  is 
a  most  troublesome  complication.  It  must  be  treated  by 
frequent  irrigation  of  the  rectum  with  weak  antiseptics 
and  improving  the  patient's  general  condition  by  stimu- 
lants and  good  food.  It  can  be  avoided  by  careful 
attention  to  asepsis  during  and  after  the  operation. 

Stricture  should  not  occur  if  the  operation  has  been 
properly  done,  but  should  there  be  any  tendency  of 
narrowing  of  the  anal  orifice  it  must  be  met  by  the  daily 
passage  of  bougies,  and  the  patient  should  be  instructed 
to  pass  a  bougie  for  himself  until  all  tendency  to  con- 
traction has  disappeared.  Allingham's  bougies,  which 
are  only  tapered  at  the  extreme  end,  are  the  best  for  this 
purpose.  The  results  of  a  stricture  of  the  anus  are  so 
serious  that  the  greatest  care  should  be  taken  to  prevent 
it  becoming  permanent.  Stricture  can  only  occur  if  the 
operation  has  been  badly  done  or  there  has  been  ulcera- 
tion. 

After  Whitehead's  operation  the  treatment  is  the  same. 
A  finger  should  be  occasionally  passed  into  the  bowel  to 
ascertain  if  the  parts  are  uniting  correctly.  The  stitches 
uniting  the  mucous  membrane  to  the  skin  should  be 
allowed  to  come  away  by  themselves.  If,  as  sometimes 
happens,  the  mucous  membrane  tears  away  and  retracts, 
the  condition  should  not  be  left  to  heal  by  granulation  or 
a  serious  stricture  will  probably  result.  i\n  anaesthetic 
should  be  administered,  and  the  mucous  membrane 
pulled  down  and  reunited  to  the  skin  margin  by  stitches. 

Retention  of  Urine. — This  is  very  common  for  the  first 
day  or  so  after  all  operations  on  the  rectum,  and  more 
particularly  if  the  anterior  wall  has  been  interfered  with 
— as,  for  instance,  by  the  ligature  of  a  pile  in  this  situa- 


Operations  on  the   Rectum  235 

tion.  The  patient  should  be  encouraged  to  try  and  pass 
his  water  naturally  if  possible,  and  may  be  allowed  to 
kneel  up  in  the  bed  for  the  purpose.  Should  he  still  be 
quite  unable  to  pass  his  water,  a  soft  Jaque's  catheter 
may  be  passed  and  the  urine  drawn  off.  The  retention 
often  lasts  for  several  days. 

Sometimes  after  an  operation  for  haemorrhoids  one  or 
more  external  piles  form  at  the  anal  margm.  These  are 
due  to  oedema  of  the  skin  at  the  anal  margin  from  the 
circulation  being  interfered  with  by  the  removal  of  the 
piles.  They  are  not  of  much  consequence,  and  will 
subside  as  the  circulation  is  re-established.  The  follow- 
ing ointment  applied  on  a  piece  of  cotton-wool  will 
relieve  any  pain  they  may  cause,  and  also  hasten  their 
resolution.  A  compress  of  lead  lotion  may  also  be  used 
for  the  same  purpose.  If  very  large  they  may  be  cut  off 
under  local  anaesthesia. 


^  Hydrarg.  subchlor. 

- 

« 

-     gr.  iv. 

Pulv.  opii   - 

• 

- 

.     gr.  iii, 

Extr.  belladonnas - 

. 

- 

-     gr.  iii. 

Unguent,  sambuci 

. 

. 

-    3i. 

Mitte. 

Operations  for  Fissure. 

The  after-treatment  is  practically  the  same ;  the  recum- 
bent position  should  be  maintained  until  the  wound  has 
healed.  The  dressing  should  be  changed  twice  a  day, 
and  the  parts  well  washed  with  warm  water.  A  small 
wisp  of  wool  placed  in  the  wound  with  a  probe  makes 
the  best  dressing. 

Colotomy. 

After  the  operation  the  patient  should  have  a  small 
pillow  placed  under  the  head  and  a  bolster  under  the 
knees.     If  he  complains  of   being  uncomfortable  from 


236    The  After-Treatment  of  Operations 

lying  on  the  back,  he  may  be  allowed  to  turn  on  the 
side,  providing  that  he  does  not  turn  on  to  the  side  on 
which  the  colotomy  wound  is  situated.  Very  httle  food 
should  be  given  until  the  intestine  has  been  opened, 
though  a  little  fluid  diet  may  be  allowed.  Old  people 
should  be  well  propped  up,  almost  into  a  sitting  position, 
as  this  will  prevent  any  tendency  that  they  may  have 
towards  bronchitis,  etc. 

If  the  patient  is  comfortable  the  wound  need  not  be 
dressed  on  the  day  after  the  operation.  On  the  second  day 
it  should  be  dressed,  and  the  intestine  opened  for  about 
I  inch  in  a  transverse  direction  with  a  pair  of  scissors. 
After  this  it  is  a  good  thing  to  open  the  bowels  with 
9,  mild  purgative,  such  as  ^  ounce  of  castor  oil.  On 
the  tenth  day  the  intestine  must  be  completely  divided 
in  a  transverse  direction,  and  the  clip,  or  whatever  has 
been  used  to  form  the  spur,  removed.  Any  bowel  that 
projects  above  the  skin  should  be  cut  away  with  scissors. 
The  best  control  is  obtained  by  an  opening  in  which  the 
mucous  membrane  meets  the  skin  at  the  margin  of  the 
opening  without  there  being  any  prolapse.  After  this  a  pad 
should  be  applied  to  the  wound,  and  a  firm  bandage  applied 
over  it  to  push  back  the  gut  and  get  it  to  retract  back  flush 
with  the  skin.  There  is  often  a  little  bleeding  after  the  gut 
is  divided.  This  bleeding  generally  comes  from  numerous 
small  points,  and  if  attempts  are  made  to  sponge  away  the 
clots  and  clip  the  vessels,  they  are  often  not  only  unsuc- 
cessful, but  may  result  in  the  bleeding  being  made  worse, 
The  best  thing  to  do  is  to  put  on  a  pad  of  wool,  and  exert 
firm  pressure  with  a  bandage  over  the  wound.  This  is  all 
that  is  usually  necessary.  Of  course,  if  there  is  any  vessel 
spurting,  it  should  be  caught  in  a  clip,  the  clip  either 
being  left  on  or  the  vessel  tied  in  the  usual  way.  If  the 
incision  is  made  at  right  angles  to  the  line  of  the  gut, 


Operations  on  the  Rectum  237 

there  is  seldom  any  bleeding  of  moment.  When  no  spur 
has  been  formed,  it  is  sometimes  not  easy  to  find  the  gut 
when  it  is  desired  to  open  it,  as  it  is  covered  in  lymph, 
and  may  be  unrecognisable.  Under  these  circumstances 
an  incision  must  be  made  with  a  knife  into  the  centre 
of  the  wound,  until,  by  the  escape  of  flatus,  it  is  known 
that  the  gut  is  opened,  and  then  the  incision  may  be  en- 
larged with  scissors  to  the  required  size.  The  division  of 
the  intestine  is  quite  painless  and  no  anaesthetic  is  required. 
After  the  gut  has  been  opened,  the  colon  should  be  well 
cleared  of  any  accumulated  faeces  it  may  contain  by  suit- 
able purgatives.  After  this  has  been  done,  however,  it  is 
best  not  to  make  use  of  purgatives  at  all,  unless  absolutely 
necessary,  as  they  are  very  liable  to  set  up  a  sort  of 
diarrhoea,  and  cause  soreness  of  the  skin  round  the  wound. 

If  there  are  faeces  in  the  lower  and  now  useless  portion 
of  the  colon,  they  may  be  washed  out  by  syringing 
through  from  the  upper  opening,  or  by  enemata.  In 
about  a  fortnight  from  the  operation  the  wound  will  be 
sufficiently  healed  to  have  a  colotomy  belt  fitted.  The 
best  sort  of  belt  is  that  with  a  celluloid  cup  fitting  over 
the  opening  in  the  intestine,  and  kept  in  place  by  a 
belt  with  an  indiarubber  interval  in  it  where  the  cup 
comes.  These  belts  are  much  more  comfortable  than 
those  with  a  plug  fitting  into  the  gut,  and  are  quite 
as  efficient  in  preventing  the  escape  of  faeces.  The 
same  remarks  apply  equally  to  both  lumbar  and  inguinal 
colotomy. 

Colotomy  Belts. — These  are  mainly  of  two  kinds — 
those  with  a  plug  which  fits  into  the  opening,  and  those 
with  a  cup  which  fits  over  the  ends  of  the  gut.  The  cup 
is  by  far  the  best  form.  The  chief  objection  to  the  plug 
belt  or  truss  is  that  the  presence  of  the  plug  in  the 
intestine  gives  the  patient  the  feeling  of  a  constant  desire 


2j8    The  After-Treatment  of  Operations 

to  evacuate  something  from  the  opening ;  it  also  prevents 
the  establishment  of  any  sphincter  action  at  the  artificial 
opening.  The  cup  form  does  not  possess  any  of  these 
disadvantges.  It  consists  of  a  celluloid  cup  with 
buttons  on  the  outer  side,  and  a  belt  which  fits  round  the 
patient's  body  ;  the  belt  is  made  of  indiarubber  where  it 
passes  over  the  cup.  This  holds  the  cup  in  place,  and 
insures  it  being  kept  well  up  against  the  abdominal 
wall. 


CHAPTER  XVII 

OPERATIONS  ON  THE  JOINTS 

There  are  some  features  with  regard  to  operations  upon 
joints  that  require  special  notice.  There  are  probably 
no  operations  in  surgery  after  which  sepsis  is  more 
dreaded  or  more  prone  to  occur,  if  the  most  rigorous 
precautions  are  not  taken,  than  those  upon  joints.  The 
most  scrupulous  care  is  necessary  in  the  dressing  and 
after-treatment  of  these  cases  to  prevent  the  possibility 
of  organisms  gaining  an  entrance  and  setting  up  sepsis. 
Again,  it  is  of  the  utmost  importance  that  the  joint 
should  be  functional  after  the  operation — that  is  to  say, 
should  be  capable  of  free  and  painless  movement^  and, 
in  the  case  of  the  leg,  able  to  support  the  weight  of  the 
body — except,  of  course,  in  those  cases  where  the  joint 
is  hopelessly  disorganized,  and  the  operation  has  been 
undertaken  with  the  object  of  obtaining  a  stiff  joint,  as  in 
the  case  of  excision  of  the  knee  for  tubercle. 

After  the  cavity  of  a  joint  has  been  opened,  or  the 
synovial  membrane  interfered  with,  there  is  a  great 
liability  to  the  formation  of  adhesions,  which,  if  they 
form,  may  lead  to  more  or  less  permanent  crippling,  and 
will,  in  any  case,  result  in  much  pain  to  the  patient. 
Although  these  adhesions  can  often  be  got  rid  of 
satisfactorily  later,  it  is  much  better  surgery  to  prevent 

239 


240     The   After-Treatment  of  Operations 

their  forming  at  all.  It  should  therefore  be  our  object 
to  prevent  the  formation  of  adhesions  by  moving  the 
joint  slightly  each  day  from  the  earliest  possible  date. 

After  such  operations  as  wiring  the  patella  for  fracture 
and  the  removal  of  a  fractured  or  loose  semilunar 
cartilage,  movement  of  the  joint  should  be  commenced 
on  the  second  or  third  day  after  the  operation.  In  order 
to  move  the  joint,  the  bandages  and  outer  dressings 
must  be  removed,  and  the  attendant  should  then  pass 
his  hand  (we  will  assume  that  he  is  dealing  with  the 
knee-joint)  under  the  knee,  and  gently  raise  it  off  the 
back  splint  (if  one  has  been  used),  while  with  the  other 
hand  he  holds  the  dressings  in  place,  and  supports  the 
wound  by  firm  pressure,  so  that  no  tension  is  put  upon 
the  skin  in  the  neighbourhood  of  the  wound.  On  the 
first  occasion  the  joint  should  only  be  moved  slightly  two 
or  three  times,  the  knee  being  gentl}'  raised,  and  then 
allowed  to  assume  its  original  position  by  its  own  weight. 
At  the  same  time  the  patella  should  be  moved  from  side 
to  side,  so  as  to  prevent  the  formation  of  adhesions 
between  it  and  the  anterior  surface  of  the  femur. 

This  must  be  repeated  each  day,  and  after  two  or 
three  days  the  patient  should  be  made  to  move  the  joint 
for  himself,  the  attendant  at  most  only  steadying  the  limb 
and  dressings.  The  joint  at  this  period  should  be  moved 
through  a  much  larger  angle  than  at  first.  It  is  better 
not  to  use  a  splint  in  these  cases,  but  if  one  has  been 
used  it  should  be  dispensed  with  as  soon  as  possible. 
At  the  end  of  ten  days,  when  the  wound  should  have 
healed,  the  stitches  can  be  removed,  and  a  dressing  of 
collodion  and  gauze  applied  in  such  a  way  as  to  hold 
together  the  edges  of  the  wound  and  so  support  the 
scar,  and  prevent  its  being  stretched  during  movement 
of  the  joint. 


Operations  on  the  Joints  241 

The  patient  should  now  be  encouraged  to  move  the 
joint  as  much  as  possible,  and  a  very  good  plan  in  the 
case  of  the  knee  is  to  let  the  patient  sit  on  the  edge  of 
the  bed  with  the  leg  hanging  over  the  edge,  and  the  foot 
resting  on  a  stool  of  appropriate  height ;  he  must  then 
raise  the  foot  off  the  stool  by  extending  the  knee,  and 
then  slowly  lower  it  back  again  on  to  the  stool ;  this 
should  be  repeated  for  fifteen  minutes  twice  a  day.  At 
this  period  massage  to  the  muscles  moving  the  joint  (in 
this  case  those  of  the  leg  and  thigh)  is  very  beneficial, 
both  in  keeping  up  the  tone  and  development  of  the 
muscles  and  in  getting  rid  of  any  adhesions  that  may 
have  formed.  The  scar  should  be  moved  from  side  to 
side  on  the  deeper  tissues  each  day  to  prevent  it  from 
becoming  adherent  to  the  bone,  which  otherwise  is  very 
likely  to  take  place  and  be  the  cause  of  pain  later  on. 
After  the  removal  of  a  loose  semilunar  cartilage  from  the 
knee  there  is  often  a  tendency  for  the  scar  to  become 
adherent  to  the  inner  condyle  of  the  tibia,  and  if  this  is 
allowed  to  take  place  a  considerable  amount  of  pain  and 
disability  may  result. 

After  the  operation  for  loose  semilunar  cartilage  or 
fractured  patella,  the  patient  may  usually  be  allowed  to 
walk  as  soon  as  ever  the  wound  has  healed.  It  is 
not  advisable  for  the  patient  to  wear  any  sort  of  support 
to  the  knee  as  it  tends  to  limit  movement  and  prevent 
the  proper  development  of  the  muscles  supporting  the 
joint,  on  the  integrity  of  which  the  subsequent  stability 
or  otherwise  of  the  joint  mainly  depends. 

Excision  of  the  Elbow. 

After  excision  of  the  elbow-joint  our  object  is  to  form 

a  '  false  joint,'  and  therefore  movement  must  be  com- 

16 


^4^    The  After-Treatment  of  Operations 

menced  early.  The  best  plan  is  to  fix  the  arm  in  a 
metal  outside  splint  with  a  joint  opposite  the  elbow  and 
with  a  thumb-screw,  so  that  the  splint  can  be  fixed  at  any 
desired  angle  at  will,  olr  by  loosening  which  the  splint 
caii  be  made  to  move  with  the  arm.  Each  day  the 
thumb-screw  can  be  loosened  and  the  joint  moved  with- 
out removing  the  splint ;  the  splint  must,  however,  be 
removed  from  time  to  time,  so  as  to  allow  of  movements 
of  pronation  and  supination  being  carried  out.  In  these 
movements,  while  the  wrist  is  being  rotated  the  surgeon 
must  fix  the  ulna,  to  insure  the  movements  taking  place 
correctly.  At  first  the  joint  should  be  only  slightly 
moved,  commencing  about  a  week  or  ten  days  after 
the  operation,  and  all  movements  must  be  very  gentle. 
As  the  wound  heals  the  movements  should  be  extended 
until  they  are  free  in  all  normal  directions.  The  hand 
should  be  left  free  from  the  first,  and  the  patient  en- 
couraged to  use  the  fingers  and  wrist  freely. 

As  soon  as  ever  the  parts  are  sufficiently  firm  to  allow 
of  it,  the  splint  should  be  left  off  and  the  patient  made  to 
use  the  limb ;  the  arm  can  be  kept  in  a  sling  for  part  of 
the  day  at  first,  and  a  sling  should  be  used  as  a  protection 
against  injury  while  out  of  doors  for  some  months. 
Later  on,  when  the  parts  have  thoroughly  consolidated, 
massage  and  regular  exercises  in  a  gymnasium  are  very 
useful  in  getting  back  power  and  free  movement  in  the 
arm. 

It  will  probably  be  several  months  before  real  stability 
of  the  new  joint  is  obtained,  but  in  favourable  cases  the 
patient  should  at  the  end  of  three  or  four  months  be  able 
to  use  the  limb  for  all  ordinary  purposes.  Special  care 
must  be  taken  to  see  that  the  patient  is  able  to  get  the 
hand  up  to  the  back  of  the  head,  as  this  is  often  difficult 
at  first,  and  later  on  the  patient  will  find  it  no  trifling 


Operations  on  the  Joints  243 

inconvenience  not  to  be  able  to  get  his  hand  up  to  the 
back  of  his  neck  for  the  purpose  of  doing  up  a  collar- 
stud,  etc. 

Excision  of  the  Shoulder. 

After  excision  of  the  shoulder  movement  should  be 
commenced  early  and  carried  out  in  the  same  way  as  in 
the  case  of  the  elbow,  but  it  is  particularly  important  to 
insure  the  movements  taking  place  between  the  humerus 
and  the  scapula,  and  not  between  the  scapula  and  the 
trunk.  The  surgeon  should  fix  the  scapula  by  holding 
the  angle  firmly  with  his  fingers,  and  then  move  the  arm 
or  instruct  the  patient  to  do  so  for  himself ;  if  this  pre- 
caution is  not  taken,  the  movements,  and  especially  that 
of  abduction,  are  almost  certain  to  take  place  between 
the  scapula  and  the  trunk  instead  of  at  the  shoulder- 
joint. 

The  success  or  otherwise  of  most  operations  on  the 
joints  depends  to  such  a  large  extent  upon  the  care  with 
which  the  movements  are  carried  out  during  the  after- 
treatment,  that  .too  much  care  and  patience  cannot  be 
expended  upon  them ;  and  in  the  case  of  children,  who 
form  the  largest  percentage  of  the  patients,  much 
patience  and  perseverance  is  often  necessary  in  order  to 
obtain  the  desired  result.  A  certain  amount  of  pain  is 
generally  caused  by  the  movements  at  first ;  and  if  this 
is  sufficiently  severe  to  warrant  it,  an  anaesthetic  may  be 
given  occasionally  to  insure  that  free  movement  is 
obtained. 

Excision  of  the  Knee. 

Here,  in  contradistinction  to  the  case  of  the  arm,  our 
object  is  to  obtain  bony  ankylosis,  and  a  properly  fitting 
splint  which   will   not   allow  the   bones   to   get   out  of 


244    The   After-Treatment  of  Operations 

position  is  of  the  greatest  importance.  For  this  purpose 
there  is  probably  no  better  splint  than  Howe's  splint, 
though  any  form  of  well-fitting  interrupted  splint  will  do. 
There  is  often  a  considerable  amount  of  pain  after  all 
excisions,  and,  in  fact,  after  all  operations  involving  the 
cutting  of  bone.  Morphia  must  be  given  for  its  relief, 
and  in  the  case  of  young  children,  to  whom  it  is  not 
advisable  to  give  morphia,  a  few  drops  of  laudanum, 
varying  according  to  the  age  of  the  patient,  should  be 
given  in  a  glass  of  water.  Raising  the  limb,  and  espe- 
cially slinging  it  well  up  in  a  cradle,  if  the  splint  will 
allow  of  this,  often  relieves  the  pain  to  some  extent.  It 
ought  not  to  be  necessary  to  change  the  dressing  for  a 
fortnight  after  the  operation,  and  then  it  is  often  advisable 
to  administer  an  anaesthetic  for  the  first  dressing.  This 
also  enables  the  surgeon  to  thoroughly  examine  the 
wound,  and  if  any  recurrent  foci  are  found,  to  deal  with 
them.  At  the  end  of  six  weeks  to  two  months  a  well - 
fitting  leather  splint,  strengthened  up  the  back  of  the 
knee  with  a  metal  bar,  should  be  substituted  for  the 
splint  previously  used,  and  the  patient  can  then  be  got 
up.  In  about  three  months  from  the  operation  the 
patient  can  usually  be  allowed  to  walk,  but  the  splint 
should  be  worn  for  at  least  a  year,  and  in  the  case  of 
children  for  two  or  three  years.  In  children  there  is  a 
great  tendency  for  flexion  of  the  knee  to  take  place,  and 
although  this  can  often  be  prevented  by  the  prolonged 
use  of  splints,  it  cannot  always  be  so  prevented,  as  it  is 
due  to  the  unequal  growth  of  the  epiphysis,  and  in  these 
cases  a  subsequent  partial  resection  is  necessary  later  on 
to  remedy  the  deformity. 


operations  on  the  Joints  245 

Excision  of  the  Hip. 

After  excision  of  the  hip-joint  the  two  most  important 
points  that  have  to  be  attended  to  are :  (i)  To  prevent 
external  rotation  of  the  lower  fragment ;  (2)  to  prevent 
flexion  of  the  hip-joint.  In  fact,  the  case  has  to  be 
treated  in  very  much  the  same  way  as  for  fracture  of  the 
neck  of  the  femur. 

It  is  generally  advisable  to  apply  an  extension  by 
weight  and  pulley  to  the  foot  of  the  affected  limb.  The 
extension  strapping  should  always  be  carried  above  the 
knee,  and  in  children  it  is  better  to  affix  longitudinal 
pieces  of  strapping  up  the  sides  of  the  limb  and  to 
bandage  over  these  with  an  ordinary  bandage,  afterwards 
applying  circular  strips  of  strapping  in  two  or  three 
places  so  as  to  prevent  its  coming  undone.  The  upper 
ends  of  the  side-pieces  should  be  turned  down  on  them- 
selves, and  fixed  with  strapping  so  as  to  prevent  their 
drawing  through.  This  is  much  less  irritating  to  the 
delicate  skin  of  a  child  than  applying  strapping  all  the 
way  up  the  limb.  A  long  Liston  or  Dessault's  splint 
should  be  applied  from  the  axilla  to  the  ankle,  so  as  to 
prevent  flexion  at  the  hip.  In  young  children  it  is  better 
to  use  a  Phelps's  box-splint  or  a  double  Thomas's  splint. 
If  a  long  splint  is  applied  it  must  not  be  put  on  so  tightly 
as  to  interfere  with  the  extension.  The  body  should  be 
steadied  by  passing  a  sheet  across  the  trunk  and  holding 
it  in  position  with  sand-bags  on  each  side  of  the  body, 
the  sand-bags  being  rolled  up  in  the  sheet  on  each  side. 
To  prevent  rotation  of  the  limb  a  cross-bar  should  be 
attached  to  the  long  splint  just  above  the  ankle,  or  a 
very  good  plan  is  to  fix  a  flat  piece  of  wood  at  right 
angles  across  the  back  of  the  knee  with  plaster  of  Paris 
bandages.     In  some  cases  the  limb  can  be   kept   trom 


246    The  After-Treatment  of  Operations 

rotating  by  the  use  of  a  sand-bag  placed  on  each  side  of 
the  thigh. 

The  limb  after  excision  should  be  fixed  in  a  position  of 
slight  abduction,  as  this  enables  the  patient  later  on  to 
overcome  the  shortening  of  the  limb,  which  of  necessity 
follows  excision  by  tilting  the  pelvis  down  on  the  affected 
side.  It  is  often  possible  to  obtain  a  more  or  less 
movable  false  joint  after  excision  of  the  hip  by  moving 
the  joint  two  or  three  times  each  week  after  the  wound 
has  healed. 

At  the  end  of  five  or  six  weeks  a  Thomas's  hip-splint, 
if  it  has  not  been  used  from  the  first,  may  be  fitted,  and 
the  patient  can  then  be  got  out  of  bed.  No  weight, 
however,  should  be  borne  on  the  limb  for  several  months 
even  with  the  splint  on.  If  the  child  is  old  enough  he 
may  be  allowed  to  get  about  with  crutches  and  a  patten 
on  the  boot  of  the  sound  leg.  In  young  children  it  is 
better  to  fit  £  double  Thomas's  hip-splint  with  a  pelvic 
band.  After  the  Thomas's  splint  has  been  fitted,  the 
patient  should  be  got  out  of  doors  for  several  hours  daily 
if  possible.  Some  surgeons  prefer  to  use  a  splint  of 
plaster  of  Paris  or  leather,  which  encircles  the  pelvis  and 
comes  down  below  the  knee.  The  use  of  removable 
splints  is,  however,  always  preferable  to  the  use  of  fixed 
splints ;  when  a  Thomas's  splint,  however,  fails  to  keep 
the  limb  in  good  position,  a  properly-fitting  leather  splint 
may  be  tried. 

Regular  massage  of  the  muscles  is  of  the  greatest 
benefit  in  preventing  wasting  and  in  maintaining  the 
proper  nutrition  of  the  limb  after  excision  of  the  hip 
when  the  circumstances  of  the  patient  will  allow  of  its 
being  carried  out.  All  the  muscles  of  the  limb  should 
be  massaged  regularly  two  or  three  times  a  week 
throughout  the  treatment  if  possible,  and  when  a  false 


Operations  on  the  Joints  247 

joint  is  desired  suitable   movements  may  be  combined 
with  it. 

The  after-treatment  of  osteotomy  undertaken  for  the 
relief  of  deformity,  as  in  the  case  of  coxa  vara  or  genu 
valgum,  is  practically  the  same  as  the  treatment  of  a 
fracture  of  the  bone  in  this  situation.  Special  care 
should  be  taken  to  see  that  the  movements  of  the  joint 
in  the  vicinity  of  the  operation  are  maintained  during 
the  period  of  rest  necessary  for  the  consolidation  of  the 
bone, 

Massag-e. 

Massage  is  of  the  greatest  value  after  many  operations 
in  bringing  the  muscles  back  to  their  normal  condition  of 
tone,  etc.  Massage  does  not  take  the  place  of  active 
exercise,  either  in  developing  the  muscles  or  in  improving 
the  general  circulation,  but  it  gives  us  a  most  valuable 
means  of  passing  from  the  condition  of  complete  rest 
to  that  of  ordinary  activity  without  the  transition  being 
too  sudden.  It  also  acts  as  a  very  good  substitute  for 
exercise  when  rest  is  necessary.  In  cases  of  long  and 
exhausting  illness  following  operations,  when  the  patient 
is  obliged  to  remain  in  the  recumbent  position  for  many 
weeks  or  months,  general  massage  is  of  great  value ;  it 
promotes  absorption  and  secretion,  keeps  the  skin  acting 
properly,  and  often  enables  the  patient  to  sleep  naturally, 
besides  very  considerably  diminishing  the  period  of  sub- 
sequent convalescence. 

Massage  must  be  commenced  gently  at  first ;  the  time 
occupied  and  the  force  used  may  be  increased  as  the 
patient  becomes  accustomed  to  the  treatment.  Exhaus- 
tion must  never  be  produced.  Massage  should  always 
bQ  accompanied  by  passive  or,  if  possible,  active  move- 


248    The  After-Treatment  of  Operations 

ments  of  the  joints  and  respiratory  exercises.  Ten 
minutes  a  day  is  probably  enough  at  first,  and  this  time 
can  be  increased  up  to  half  an  hour  or  an  hour.  When 
possible  the  massage  should  be  carried  out  by  a  properly 
trained  masseur ;  if  this  is  not  possible  the  nurse  or  some 
intelligent  relation  of  the  patient  may  be  instructed  in 
the  treatment.     There  are  several  varieties  of  massage  : 

Effleurage,  or  Rubbing. — This  consists  in  stroking 
and  rolling  the  skin  and  underlying  muscles  with  the 
hand,  in  a  direction  towards  the  trunk — i.e.,  in  the  direc- 
tion of  the  venous  circulation.  It  must  be  commenced 
lightly  and  gradually  increased  in  strength,  the  hand  of 
the  operator  being  made  to  grasp  the  muscles  more  and 
more  firmly. 

Petrissage,  or  Kneading. — This  consists  in  knead- 
ing and  squeezing  the  muscles  between  the  thumb  and 
fingers  and  the  edge  of  the  hand.  It  has  for  its  object 
the  increase  in  the  flow  of  blood  and  lymph  through  the 
muscles  towards  the  heart. 

Friction. — This  is  practised  by  firmly  rubbing  the 
skin  in  a  direction  towards  the  heart  with  the  closed  fists 
or- finger-tips. 

Tapotement. — This  consists  of  rapid  blows  delivered 
at  right  angles  to  the  surface  with  the  edges  of  the  two 
hands  (the  ulna  border).  This  method  of  massage  stimu- 
lates the  muscle  and  causes  local  contractions.  It  is  one 
of  the  more  vigorous  methods  of  massage,  and  must  not 
be  used  when  dealing  with  damaged  tissues  or  weakly 
subjects. 

Exercises. 

The  use  of  appropriate  exercises  after  some  operations, 
especially  those  which  affect  joints,  is  of  considerable 
importance.     The   great  point  in  dealing  with   injured 


Operations  on  the  Joints  249 

joints  or  muscles  is  to  persuade  them  to  move  rather 
than  to  compel  them  to  do  so.  Thus  the  patient,  sup- 
posing that  he  is  able  to  move  the  injured  joint  within  a 
certain  angle,  should  exercise  it  by  moving  it  within  that 
angle,  and  should  try  each  time  to  increase  the  range 
of  movement.  To  assist  the  patient  in  this,  the  best 
apparatus  is  a  cord  running  through  a  pulley,  to  one  end 
of  which  a  weight  is  attached,  and  to  the  other  a  suitable 
handle  ;  the  patient  should  then  use  the  apparatus  in  such 
a  way  that  the  weight  assists  the  movement  instead  of 
hindering  it.  For  instance,  in  the  case  of  a  more  or  less 
stiff  knee,  the  cord  from  the  pulley  should  be  attached  to 
the  ankle  in  such  a  way  that  the  weight  will  assist 
flexion. 


CHAPTER  XVIII 

THE  AFTER-TREATMENT  OF  AMPUTATIONS,  AND 
SOME  SPECIAL  OPERATIONS 

Aftep-Treatment  of  Amputations. 

Complications. — (i)  Shock  ;  (2)  haemorrhage  ;  (3)  pain  ; 
(4)  adherent  cicatrix  ;  (5)  conical  stump ;  (6)  persistent 
•  sinus. 

After  the  operation  the  stump  should  be  elevated  as 
much  as  possible  and  steadied  with  sand-bags,  as  spasm 
of  the  muscles  is  very  apt  to  take  place,  and  this  will  tend 
to  displace  the  dressings  ;  this  spasm  of  the  muscles  can 
be  relieved  to  some  extent  by  applying  a  very  hot  rubber 
water-bottle  to  the  outside  of  the  bandages,  and  by  the 
use  of  morphia  injections.  As  a  rule,  the  dressings  require 
changing  on  the  day  following  the  operation,  as  there 
is  generally  a  considerable  amount  of  oozing  during  the 
first  twenty-four  hours ;  the  drainage-tube  should  be 
removed  as  soon  as  ever  the  amount  of  oozing  is  suffi- 
ciently diminished  to  warrant  it.  A  kind  of  dark-brown 
discharge,  which  probably  comes  from  the  end  of  the 
bone,  not  infrequently  persists  for  a  considerable  time  in 
unhealthy  individuals,  and  in  these  cases  the  drainage- 
tube  must  be  retained  longer. 

After  the  wound  has  almost  healed  and  the  stitches 
have  been  removed,  it  is  advisable  in  many  cases  to  apply 

25Q 


The  After- Treatment  of  Amputations   251 

some  sort  of  support  to  the  flaps  to  prevent  stretching  of 
the  scar,  and  to  hasten  heahng  and  consoHdation  of  the 
end  of  the  stump.  This  is  particularly  the  case  when 
a  large  muscle  flap  has  been  formed,  as  in  Faraboeuf's 
amputation  of  the  leg,  Teal's  amputation,  and  most  ampu- 
tations through  the  thigh. 

The  edges  of  the  flaps  should  be  drawn  together  by 
large  broad  pieces  of  strapping  ;  the  tissues  of  the  stump 
being  well  drawn  down  over  the  bone  before  the  free 


Fig.  34. — Method  of  applying  Strapping  to  the  Stump. 

end  of  the  piece  of  strapping  is  fixed.  The  stump  must 
next  be  bandaged  from  above  down — that  is,  towards  the 
extremity,  so  as  to  draw  down  and  support  the  muscles, 
and  prevent  them  from  pulling  the  skin  and  tissues  tight 
over  the  end  of  the  bone.  A  linen  bag  made  to  fit  the 
stump  like  a  sock  should  then  be  placed  over  all,  and  fixed 
by  tapes  round  the  waist  or  joint  above  the  amputation. 
If  no  such  bag  is  obtainable  an  ordinary  stump-bandage 
may  be  applied.  An  excellent  description  of  the  methods 
of  bandaging  stumps  after  amputation  will  be  found 
in  '  A  Manual  of  Surgical  Treatment,'  by  Cheyne  and 
Burghard. 

Pain. — The  pain  after  amputations  is  usually  of  a 
neuralgic  type,  and  is  probably  due  to  the  contraction  of 
the  scar  tissue  at  the  ends  of  the  nerves,  which  have  been 


252    The  After-Treatment  of  Operations 

cut ;  these  attacks  of  neuralgic  or  starting  pains  often 
persist  for  several  months  after  an  amputation,  and  then 
gradually  cease.  At  first  they  often  cause  the  patient  con- 
siderable distress,  but  ^his  varies  very  much  in  different 
individuals.  Hot-water  bottles  or  hot  stupes  applied 
over  the  main  nerves  above  the  stump  will  often  reHeve 
the  pain  ;  thus  in  the  case  of  the  leg  the  heat  should  be 
applied  over  the  sacral  region  or  upper  part  of  the  back 
of  the  thigh,  and  in  the  arm  over  the  clavicle  and 
scapula. 

Adherent  Cicatrix. — This  is  a  most  troublesome  con- 
dition, and  should  be  prevented  by  gently  moving  the 
scar  on  the  deep  tissues  daily  after  the  wound  has  healed ; 
the  patient  can  easily  do  this  for  himself.  If  the  cicatrix 
is  allowed  to  become  adherent,  it  is  often  the  cause  of 
constant  pain  and  tenderness  at  the  end  of  the  stump, 
and  not  infrequently  results  in  chronic  and  intractable 
ulceration  of  the  scar  later  on.  Should  the  cicatrix 
become  adherent,  an  attempt  may  be  made  by  gentle 
massage  to  loosen  it  from  the  bone  ;  and  if  this  is  in- 
effectual, the  scar  must  be  loosened  by  cutting  it  away 
from  the  bone  with  a  tenatome,  and  then  moving  it 
frequently  to  prevent  it  again  becoming  adherent. 

Conical  stump  is  generally  the  result  of  a  faulty  opera- 
tion, but  in  children  is  liable  to  occur,  however  carefully 
the  amputation  has  been  planned.  This  is  due  to  the 
growth  of  the  bone,  the  latter  tending  to  grow  through 
the  end  of  the  stump.  It  may  be  to  a  large  extent 
prevented  by  massage,  the  stump  being  massaged  towards 
the  end,  and  not  towards  the  body,  care  being  taken 
at  the  same  time  to  prevent  the  scar  from  becoming 
adherent ;  or  the  stump  can  be  bandaged  in  the  way 
already  mentioned  to  draw  down  the  muscles. 

Persistent   sinus   after    amputation   is  generally  due  to 


The  After-Treatment  of  Amputations  253 

some  deep  stitch  or  ligature  acting  as  a  foreign  body,  or 
to  a  piece  of  necrosed  bone ;  in  either  case  the  cause  must 
be  sought  for  and  removed. 

As  soon  as  the  wound  has  thoroughly  healed,  which 
will  usually  be  about  a  month  after  the  operation, 
the  patient  should  be  measured  for  an  artificial  limb. 
In  the  leg  (with  the  exception  of  Syme's  and  Stephen 
Smith's  amputations),  with  but  few  exceptions,  patients 
are  never  able  to  bear  any  weight  on  the  end  of  the 
stump,  nor  is  it  advisable  that  they  should  do  so ;  the 
weight  is  taken  on  the  pelvis  from  the  upper  end  of  the 
socket,  and  the  end  of  the  stump  should  not  come  into 
contact  with  the  end  of  the  socket,  but  should  be  free 
except  for  contact  with  the  sides.  In  a  below-knee 
amputation  the  weight  is  taken  on  the  sides  of  the  head 
of  the  tibia  and  on  the  condyles  of  the  femur. 

No  bad  effects  to  the  stump  need  be  anticipated  from 
fitting  an  artificial  limb  at  an  early  date.  There  is 
another  objection  that  is  commonly  brought  forward 
against  having  an  artificial  limb  fitted  at  an  early  date, 
namely,  that  so  much  contraction  of  the  stump  takes 
place  after  an  amputation  that  the  fit  of  the  socket  soon 
becomes  loose,  necessitating  a  new  limb.  This  is  not 
the  case.  It  is  true  that  a  good  deal  of  contraction 
does  occur  and  renders  the  fit  loose ;  but  this  will 
take  place  however  long  a  period  is  allowed  to  elapse 
before  fitting  the  limb,  as  a  considerable  amount  of  the 
fat  in  the  stump  disappears  after  the  limb  has  been  worn 
for  a  short  time,  and  this  makes  the  socket  fit  loosely. 
On  the  other  hand,  it  is  most  important  if  the  patient 
wishes  to  use  the  artificial  limb  with  success  that  he 
should  commence  to  use  it  before  the  muscles  moving 
the  stump  have  had  time  to  waste  and  form  adhesions- 
In  order  that  the  patient  may  obtain  the  best  results 


2  54    The   After-Treatment  of  Operations 

from  the  use  of  an  artificial  limb,  the  muscles  acting 
upon  the  stump  will  have  to  be  trained  to  their  new 
function  ;  and  if  they  have  been  allowed  to  waste  to  any 
considerable  extent  very  great  difficulty  will  be  experi- 
enced in  getting  these  muscles  to  fulfil  their  new  function. 
The  result  will  be  that  many  patients  will  give  up  the 
attempt  in  despair,  and  remain  more  or  less  hopeless 
cripples  for  the  rest  of  their  lives.  This  is  a  most 
important  point,  especially  in  old  people,  who  often  have 
neither  the  pluck  nor  the  adaptable  musculature  of  youth. 

A  very  considerable  time  is  usually  necessary  before 
a  patient  can  become  accustomed  to  the  use  of  an 
artificial  limb,  and  especially  is  this  the  case  with  the 
leg,  where  the  weight  of  the  body  has  to  be  borne. 
New  centres  of  equilibrium  have  to  be  developed  in  the 
brain  and  spinal  cord,  muscles  have  to  take  on  unaccus- 
tomed functions,  and  parts  previously  free  from  pressure 
have  to  bear  very  considerable  pressure  without  causing 
pain  or  becoming  sore.  Much  pluck  and  perseverance 
will  be  required  to  attain  these  ends,  and  it  is  of  primary 
importance  that  such  a  serious  check  as  wasted  muscles 
should  not  be  added  to  the  other  difficulties.  Should 
the  stump  shrink  much  after  the  limb  has  been  worn  for 
some  time — as  is  usually  the  case — it  can  easily  be 
remedied  by  having  the  inside  of  the  socket  built  up  with 
cork  or  other  suitable  material. 

A  very  close  fit  is  not  necessary  in  an  artificial  leg, 
and  in  the  case  of  an  arm  a  close  fit  can  be  secured  by 
means  of  lacing.  When  the  artificial  limb  is  first  worn, 
all  bandages  must  be  dispensed  with,  and  if  it  is  neces- 
sary to  support  the  scar,  a  collodion  dressing  can  be  used. 
A  woollen  sock  or  socks  should  be  worn  over  the  stump, 
to  prevent  the  skin  from  being  chafed  by  contact  with 
the  socket. 


The  After-Treatment  of  Amputations  255 

Artificial  Limbs. 

Artificial  Hand  or  Arm. — No  artificial  hand  can  be 
fitted  unless  the  amputation  is  at  or  above  the  wrist ; 
however,  two  or  even  one  finger  or  stumps  of  fingers  are 
of  more  use  to  the  patient  than  the  best  artificial  hand 
that  has  ever  been  invented.  For  an  amputation  in  the 
middle  of  the  forearm  the  limb  is  made  with  a  wooden 
socket  coming  up  to  the  elbow,  into  which  the  stump  fits 
(Fig.  35) ;  there  is  a  broad  leather  strap  round  the  lower 
part  of  the  upper  arm,  which  is  attached  to  the  socket  by 
hinges.  The  grasp  of  the  artificial  hand  is  obtained  by 
means  of  a  cord  attached  to  a  belt  round  the  opposite 
shoulder ;   a  very  slight  movement  of  the  shoulders   is 


Fig.  35. 

sufficient  to  open  the  hand,  and  by  relaxing  the  pull  on 
the  strap  the  hand  closes  by  means  of  a  spring.  After  the 
patient  has  become  accustomed  to  using  the  apparatus  a 
great  deal  of  use  can  be  made  of  it. 

For  an  amputation  above  the  elbow  the  socket  is  made 
to  come  up  over  the  shoulder,  and  is  fixed  in  place  by  a 
strap  round  the  body  (Fig.  36) ;  a  cord  is  used  in  the  same 
way  as  in  a  below-elbow  limb  for  obtaining  the  hand 
movement,  and  another  cord  passing  behind  the  shoulder 
is  used  for  obtaining  movement  at  the  elbow.  Most  of  the 
friction  comes  upon  the  sides  of  the  stump,  and  not 
upon  the  end,  so  that  a  circular  method  of  amputation  is 
particularly   well  suited  to   arm  amputations.     The  im- 


256    The  After-Treatment  of  Operations 

portant    points   about   an   artificial   arm    are   lightness, 
simplicity,  and  a  good  fit. 

To  Measure  for  an  Artificial  Arm. — Stump :  length  from 
top  of  shoulder  to  end,  length  from  point  of  axilla  to 
end,  circumference  every  2  inches.  Sound  arm :  length 
from  top  of  shoulder  to  base  of  fingers  (the  arm  being  in 
the   extended   position),  length  from   point  of  axilla  to 


Fig.  36. 

elbow,  and  from  elbow  to  wrist,  also  circumference  every 
2  inches.  If  a  below-elbow  amputation,  measure  also 
from  elbow  to  end  of  stump.  It  is  much  better  for  the 
instrument  maker  to  take  the  measurements  himself 
when  possible. 

Artificial  Legs. — It  is  practically  impossible  to  fit 
any  appliance  that  will  act  satisfactorily  to  any  amputa- 


The  After-Treatment  of  Amputations  257 


tion  of  the  foot  short  of  a  Syme's.  Such  amputations 
as  Chopart's  and  Lisfranc's  make  very  unsatisfactory 
stumps  as  a  general  rule  ;  this  is  due  to  the  lever  formed 
by  the  normal  foot  being  destroyed.  No  artificial  ap- 
pliance can  take  its  place,  as  there  is  very  little  space 
to  v^ork  in,  and  the  tapering  shape  of  the  stump  makes 
it  impossible  to  get  any  purchase  for  the  artificial  foot. 
The  best  appliance  for  such  stumps  is  a  boot  into  which 
a  piece  of  cork  has  been  fitted,  to 
fill  up  the  vacant  space  left  by  the 
removal  of  part  of  the  foot.  After 
a  Syme's  amputation  a  very  useful 
artificial  foot  can  be  fitted  (Fig.  37) ; 
the  shortening  of  the  limb  resulting 
from  the  operation  is  generally  about 
2|  inches,  vi^hich  allows  room  for  an 
artificial  ankle-joint  to  be  placed 
below  the  end  of  the  stump.  A  half- 
socket  is  made,  so  as  to  fit  up  the 
calf  of  the  leg  and  prevent  the  foot 
from  turning  forward ;  this  socket  is 
held  in  place  by  cross-straps  over 
the  shin ;  the  weight  is  taken  on  the 
end  of  the  stump.  A  Pirogoff  stump 
is  not  so  satisfactory  as  a  Syme,  as  the  shortening  of 
the  limb  afterwards  is  only  about  i  to  il  inches,  and 
this  does  not  allow  room  for  a  joint  below  the  end  of 
the  stump.  The  joint  has  in  this  case  to  be  fitted 
outside,  and  this  causes  a  very  unsightly  widening  of 
the  ankle. 

For  amputations  below  the  knee  a  socket  is  made  into 
which  the  stump  fits.  The  weight  is  taken  on  the  sides 
of  the  stump  and  on  the  head  of  the  tibia  ;  the  end  of  the 
stump  should  not  take  any  of  the  weight  (at  first,  at  any 


Fig.  37. 


258    The  After-Treatment  of  Operations 

rate).  The  limb  is  held  in  place  by  a  short  leather  socket 
fitted  round  the  lower  part  of  the  thigh  and  tightened  by 
lacing  up  the  front ;  this  leather  socket  is  attached  to 
the  wooden  one  by  side  steel  hinges  (Fig.  38).  This 
form  of  artificial  leg  works  very  well  when  the  stump 
below  the  knee  is  not  too  short ;  if  the 
stump  is  short  flexion  is  very  liable  to 
occur,  and  render  the  wearing  of  an 
artificial  leg  impossible ;  also  the  short 
stump  does  not  obtain  sufficient  purchase 
on  the  artificial  leg  to  enable  the  patient 
to  control  it.  The  so-called  seat  of  election 
probably  represents  the  very  worst  place 
that  it  is  possible  to  remove  the  leg,  if  it  is 
desired  that  the  patient  should  subse- 
quently use  an  artificial  limb. 

After  amputation  through  the  knee-joint 
the  weight  can  be  taken  on  the  end  of  the 
stump,  the  limb  being  fixed  in  place  by  a 
leather  socket  fastened  round  the  thigh  by 
lacing.  Unfortunately,  chafing  and  sore- 
ness of  the  end  of  the  stump  are  rather 
liable  to  occur,  and  as  almost  the  whole  of 
the  weight  must  of  necessity  be  taken  on 
the  end  of  the  stump,  this  may  prove  very 
troublesome ;  careful  attention  to  the  fit  of 
the  limb  will  do  much  to  get  over  this 
difficulty.  Special  attention  should  be  paid 
Fig.  38,         towards  the  prevention  of  any  lateral  play 

in  the  socket. 

For  amputations  above  the  knee,  the  weight  is  taken  on 

the  pelvis — in  fact,  the  patient  may  be  said  to  be  sitting 

on  the  top  of  the  socket ;  it  is  therefore  very  important 

that  the  upper  end  of  the  socket  should  fit  accurately 


The  After-Treatment  of  Amputations   259 

and  should  have  a  good  broad  edge  behind  (Fig.  39).  No 
weight  should,  as  a  rule,  be  taken  on  the  end  of  the 
stump,  and  the  latter  should  not  come  down  to  the  end 
of  the  socket. 

The  limb  can  be  held  in  place  either  by  means  of  a 
shoulder-strap   or   by   a   broad    belt 
round   the    waist ;    the    belt    has   a         .^^^^^»^-~ 
running  cord  and  pulleys,  one  end  of 
the  cord  being  attached  to  the  back 
of  the  limb  socket  with  a  flat  elastic  j 

strap,  and  the  other  attached  to  the  ,  ! 

front  by  an  adjustable  strap.     The  i" 

belt  is  by  far  the  better  method  of  \ .  ! 

attaching  the  limb.  \  \ 

In   having   a   suitable  instrument  j 

fitted  to  a  lower  limb  stump   it   is  ! 

important  to  see  that  the  artificial 
leg  is  strongly  made,  as  the  weight 
that  it  will  have  to  bear  is  consider-  \ 

able  (in   fact,  the  whole   weight   of  / 

the  body),  and  in  many  positions  of  ' 

the  limb  this  weight  will  be  acting 
at  great  mechanical  advantage ;  but, 
at    the    same   time,    if    the   moving  I 

parts,  and  especially  the  foot,  are 
too  heavy  the  limb   will  not  move  x' 

quickly  enough  for  easy  progression, 
and  will  tend  to  act  like  a  pendu-    '-__„      •'"" 
lum.     The  fixed  parts  of  an  artificial  pj^, 

limb — that    is   to   say,  the  socket — 
can  be  made  heavy  without  any  disadvantage ;   but  it 
is  of  the  utmost  importance  that  the  moving  parts  should 
be   light,  otherwise  a  most  unsightly  gait  will  be  the 
result. 


26o    The  After-Treatment  of  Operations 

In  the  better  class  of  artificial  limbs  sheepskin  is 
shrunk  on  to  the  surface  of  the  wood ;  this  prevents  it 
splitting,  and  enables  the  limb  to  be  made  very  light 
while  maintaining  considerable  textile  strength. 

The  important  things  to  notice  in  examining  the  fit  of 
an  artificial  limb  are  to  see  that  the  pressure  is  distri- 
buted over  a  large  area,  and  does  not  come  principally  on 
one  or  two  points,  and  to  see  that  at  first  no  pressure 
comes  on  the  end  of  the  stump,  with  the  exception  of  a 
Syme's  and  knee-stump. 

How  to  Measure  for  an  Artificial  Leg. — Length  from 
perineum  to  floor  (when  the  patient  is  standing),  length 
from  lower  edge  of  patella  to  end  of  stump,  and  on  the 
sound  side  from  same  point  to  floor.  If  for  an  above- 
knee  amputation,  length  from  perineum  to  end  of  stump, 
and  on  sound  side  from  same  point  to  lower  edge  of 
patella  ;  circumference  of  thigh  at  base  on  both  sides  and 
every  2  inches  all  the  way  down.  Then,  with  the 
patient  sitting,  and  the  knee  on  the  sound  side  bent  at 
right  angles,  measure  from  the  back  of  the  knee  to  the 
ground  and  from  the  top  of  the  knee  to  the  ground.  It 
is  much  better  for  the  instrument  maker  to  make  his  own 
measurements,  but  when  this  is  impossible,  the  above 
will  generally  prove  sufficient.  Outlines  of  the  stump 
drawn  on  paper  placed  against  the  limb  should  also  be 
sent,  and  the  size  of  boot  should  be  stated  or  an  old  boot 
sent. 

After-Treatment  of  some  Special  Operations : 
Varicose  Veins. 

Complications. — (i)  Gaping  of  the  wound  after  the 
removal  of  the  stitches  ;  (2)  sloughing  of  some  portions 
of  the  skin  edges  ;  (3)  cedema  of  the  leg. 

After  the  operation  the  limb  should  be  elevated,  either 


After-Treatment  of  Special  Operations   261 

by  supporting  the  splint  on  cushions,  or  by  slinging  it  in 
a  suitable  cradle.  There  is  no  occasion  to  change  the 
dressings  for  ten  days  or  a  fortnight  after  the  operation, 
but  it  is  as  well  to  examine  them  from  time  to  time  to 
ascertain  that  they  have  not  slipped,  and  to  see  that  they 
are  not  constricting  the  limb  above.  After  the  stitches 
have  been  removed,  the  edges  of  the  wound  should  be 
drawn  together  with  strips  of  strapping,  and  the  wound 
itself  powdered  with  boracic  powder,  and  then  the  leg 
should  be  bandaged,  from  the  foot  up,  with  a  Domet  or 
flannel  bandage.  As  a  rule,  it  is  not  advisable  for  the 
patient  to  be  allowed  to  walk  for  quite  three  weeks  after 
the  operation,  as  the  wound  after  these  operations  on  the 
veins  heals  very  slowly.  In  many  cases,  when  the 
condition  of  the  veins  before  the  operation  was  bad,  it  is 
best  to  order  an  elastic  stocking  to  be  worn  for  six  months 
afterwards.  The  elastic  stocking  must  not,  however,  be 
brought  above  the  knee.  Or  an  excellent  substitute  for 
an  elastic  stocking,  and  one  which  is  cleaner  if  the  patient 
is  intelligent  enough  to  apply  it  properly,  in  an  elastic  or 
Velpeau  bandage. 

Gaping  of  the  wound  when  the  stitches  are  removed 
cannot  always  be  prevented,  though  it  is  often  due  to  the 
edge  becoming  turned  in  when  the  wound  is  being  sewn 
up.  The  edges  should  be  brought  together  as  accurately 
as  possible,  and  held  in  position  with  small  pieces  of 
strapping. 

Sometimes  the  edges  of  the  wound  are  so  thin  and  so 
badly  nourished  that  sloughing  occurs.  This  consider- 
ably delays  the  healing,  and  it  is  best,  if  possible,  to  keep 
the  patient  in  the  recumbent  position  for  some  time 
longer,  or  else  to  prevent  movement  of  the  skin  by  the 
application  of  strapping. 

Some    oedema   of    the    lesf    is    not   uncommon   after 


262    The  After-Treatment  of  Operations 

operations  on  the  veins,  and  especially  when  the  patient 
is  first  allowed  to  get  up.  Careful  bandaging,  from  the 
foot  up  to  the  knee,  is  all  that  is  required  to  prevent 
this. 

Laminectomy. 

Complications. — (i)  Chest  troubles  ;  (2)  distension  of 
the  abdomen  ;  (3)  diarrhoea  ;  (4)  bed-sore. 

As  most  of  the  patients  on  whom  laminectomy  has 
been  performed  are  paralyzed,  the  greatest  care  is 
necessary  in  the  after-treatment,  and  the  most  skilled 
nursing  is  a  necessity.  If  the  intercostal  muscles  are 
paralyzed,  and  the  respirations  are  being  carried  out  by 
the  diaphragm  only,  chest  trouble,  usually  in  the  form  of 
moist  bronchitis,  is  very  liable  to  occur.  Coughing  is, 
under  these  circumstances,  impossible,  and  the  patient  is 
in  great  danger  of  being  unable  to  breathe,  owing  to  the 
mucus  in  the  lungs  obstructing  respiration.  When  this 
is  the  case,  an  attempt  may  be  made  to  dry  up  the 
secretion  by  the  use  of  drugs,  such  as  belladonna  and 
morphia,  and  the  patient  should  be  turned  on  to  the  side, 
so  as  to  clear  one  lung.  Expectorants  must,  of  course, 
on  no  account  be  given.  When  the  cause  of  the 
paralysis  is  high  up  in  the  cord,  distension  of  the 
abdomen  often  proves  extremely  troublesome.  The  best 
way  of  treating  this  is  by  the  use  of  the  rectal  tube,  after 
clearing  the  lower  bowel  with  enemata.  If,  as  is  often 
the  case,  this  does  not  prove  sufficient,  direct  pressure 
on  the  abdomen  while  the  tube  is  in  place  may  be 
tried.  The  pressure  can  either  be  applied  directly 
with  the  hands,  or  by  passing  a  towel  round  the 
abdomen  and  splitting  the  ends  of  the  towel,  the  ends 
being  then  passed  through  each  other,  and  pulled  upon 
from  opposite  sides  in  such  a  way  as  to  compress  the 


After-Treatment  of  Special   Operations    263 

abdomen.  In  any  case,  the  pressure  should  only  be 
exerted  during  expiration,  as  otherwise  it  may  so 
embarrass  the  respiration  as  to  prevent  the  patient  from 
breathing.  Even  after  a  successful  laminectomy  the 
paralysis  seldom  passes  off  for  some  considerable  time, 
and  recovery  is  usually  an  extremely  slow  process.  The 
condition  of  the  muscles  should  be  kept  up,  as  far  as 
possible,  by  the  use  of  massage  and  galvanism  through- 
out the  after-treatment. 

There  is,  of  course,  in  all  these  cases  of  paralysis,  a 
great  liability  to  bed-sore  and  cystitis.  The  greatest 
care  and  attention  are  necessary  to  prevent  these  com- 
plications. 


APPENDIX 


Rectal  Feeding-. 

This  may  be  either  by  means  of  rectal  suppositories  or 
by  enemata.  Rectal  suppositories  have  become  very 
popular  of  late  on  account  of  the  ease  with  which  they 
can  be  administered  and  retained  ;  but  owing  to  the  com- 
paratively small  amount  of  material  contained  in  them, 
a  very  large  number  would  have  to  be  given  in  order  to 
take  the  place  of  feeding  by  the  mouth  and  maintain  the 
patient's  weight.  A  combination  of  both  methods  of 
rectal  feeding  is  probably  the  best  in  most  cases.  If  sup- 
positories are  used,  alternate  ones  of  meat  and  milk  should 
be  introduced  every  two  hours.  A  little  vaseline  is 
smeared  on  the  suppository,  and  then  it  is  pushed  well 
up  the  rectum  above  the  internal  sphincter.  A  soap-and- 
water  enema  must  be  given  to  clear  the  rectum  once  a  day. 
When  enemata  are  used  the  lower  bowel  must  be 
well  cleared  with  a  copious  warm-water  enema  adminis- 
tered half  an  hour  before  the  nutrient.  The  patient 
should  lie  on  the  left  side  near  the  edge  of  the  _  bed,  and 
have  the  buttocks  raised  slightly;  a  No.  lo  or  12  soft 
Jacque's  catheter  should  be  passed  well  up  into  the 
rectum,  a  little  vaseline  or  glycerine  being  first  smeared 
on  it  to  facilitate  introduction ;  a  glass  funnel  is  then 
attached  to  the  free  end  of  the  catheter,  and  the  nutrient 
enema  allowed  to  flow  in  slowly.  If  it  is  allowed  to  flow 
in  too  quickly  there  will  be  difficulty  in  getting  the 
patient  to  retain  it.  After  the  enema  the  patient  should 
lie  quiet  without  moving  for  about  an  hour. 

264 


Appendix  265 

The  quantity  of  the  enema  should  be  from  about  5  to 
7  ounces  of  fluid.  If  there  is  difficulty  in  getting  the 
enema  retained,  the  addition  of  a  little  claret  or  burgundy 
will  often  prove  effectual,  or  10  minims  of  tinct.  opii  can 
be  added  to  the  enema.  All  nutrient  enemata  should  be 
digested  before  being  used  either  with  Benger's  liquor 
pancreaticus  or  any  of  the  numerous  other  peptonizing 
materials.  It  has  been  shown  that  the  addition  of 
common  salt  to  egg-albumin  renders  it  capable  of 
absorption  by  the  rectal  wall  as  readily  as  peptonizing 
it  would  do,  and  it  has  not  the  disadvantage  of  being 
irritating,  as  is  the  case  with  most  of  the  fluid  peptones. 
All  nutrient  enemata  should  be  used  at  body  temperature. 

The  ease  with  which  the  different  food -stuffs  are 
absorbed  by  the  rectum  varies  greatly.  Milk  is  very 
extensively  used  as  a  medium  for  enemata,  although  its 
proteids  are  not  well  absorbed  by  the  rectal  wall ;  egg- 
albumin  is  well  absorbed  if  combined  with  a  certain 
amount  of  common  salt.  Raw-beef  juice  is  probably  the 
best  absorbed  of  any  of  the  proteid-yielding  foods.  Sugar 
is  well  absorbed,  but  has  the  objection  that  it  is  very 
irritating  to  the  rectal  mucous  membrane,  and  conse- 
quently is  not  well  retained  ;  it  should  only  be  used  in 
dilute  solutions.  Raw  starch  is  very  easily  absorbed, 
and  has  not  the  same  objection  as  sugar  ;  fats  are  very 
slightly  absorbed,  and  are  practically  useless  for  rectal 
alimentation. 

The  following  enemata  are  easily  absorbed,  and  can  be 
recommended : 

(i)  White  of  three  eggs.  (2)  Ox  serum,  5  ounces. 

Milk,  4  ounces.  Milk,  2  ounces. 

Starch  (raw),  i  ounce.  Starch,  6  ounces. 

Salt,  ^  ounce. 

(3)  Grape  sugar,  60  grammes. 
Milk,  250  c.c. 

One  of  the  above  enemata  should  be  administered 
every  six  hours. 

The  following  nutrient  enema  is  highly  recommended 
by  Ewald  :  Two  tablespoonfuls  of  wheat-flour  are  stirred 
up  with  150  c.c.  of  lukewarm  water  or  milk.  To  this 
one  or  two  eggs  and  a  pinch  of  salt  are  added,  and  the 


266    The  After-Treatment  of  Operations 

whole  is  beaten  up  with  50  c.c.  of  a  15  per  cent,  solution 
of  grape-sugar,     A  little  claret  may  be  added. 

If  no  fluids  are  being  administered  by  the  mouth,  a 
large  warm-water  enema  must  be  given  once  or  twice 
daily  to  supply  the  proper  complement  of  fluid. 

Nasal  Feeding". 

This  is  most  commonly  used  in  children  when  forced 
feeding  is  necessary,  and  also  after  certain  operations  on 
the  mouth,  when  it  is  desirable  not  to  allow  mastication 
or  swallowing.  It  is  also  sometimes  necessary  after 
tracheotomy  and  certain  operations  on  the  larynx  to  pre- 
vent food  getting  into  the  air-passages.  The  child  should 
be  placed  lying  down  on  its  back,  and  an  assistant  should 
be  at  hand  to  hold  the  head.  A  soft  rubber  catheter, 
No.  4  or  6  (according  to  the  age  and  size  of  the  child),  is 
then  passed  along  the  floor  of  the  nose  until  it  reaches 
the  posterior  pharyngeal  wall,  and  then  it  must  be 
pressed  steadily  on  until  the  stomach  is  reached ;  a 
funnel  is  attached  to  the  end  of  the  catheter,  and  a  fluid 
feed  allowed  to  run  in  slowly,  the  amount  introduced 
being,  of  course,  the  same  as  would  be  given  by  the 
mouth. 

Subcutaneous  Feeding-. 

This  is  not  a  very  common  method  of  feeding,  but  is 
one  that  in  certain  cases  may  prove  useful.  As  an  acces- 
sory to  rectal  feeding,  it  may  prove  very  useful  in  cases 
where  a  patient  is  failing  rapidly  from  want  of  nourish- 
ment ;  and  in  cases  where  the  patient  cannot  swallow 
and  the  rectum  has  become  irritable  and  will  not  retain 
nutrient  enemata  it  can  be  used  for  a  few  days  till  the 
rectum  has  had  time  to  recover.  Patients  have  been 
kept  alive  for  many  days  without  losing  weight  by  this 
method  of  feeding  alone.  The  food  used  must  be  able  to 
be  sterilized,  and  must  be  of  such  a  nature  that  it  needs 
no  digestion,  A  10  per  cent,  solution  of  grape-sugar  can 
be  used,  but  is  very  apt  to  set  up  irritation  at  the  site  of 
injection.  Sterilized  olive  oil  seems  to  give  the  best 
results  :   30  to  40  c.c.  of  sterilized  olive  oil  should  be 


Appendix  267 

injected  into  the  subcutaneous  cellular  tissue  of  the 
groin  with  a  sterilized  glass  syringe.  The  oil  should  be 
injected  slowly,  and  it  is  best  not  to  inject  it  all  in  one 
place,  but  to  inject  the  30  c.c.  in  two  or  three  different 
places.  The  injection  should  only  be  done  once  a  day. 
and  the  part  should  be  massaged  after  the  injection  to 
promote  absorption. 

The  following  is  recommended  by  Freidrick  for  use 
as  a  subcutaneous  food 


Sodium  chloride 
Grape-sugar 
Peptone 
Water 


0-2 

3-5 

67 

-  to  100 


It  should,  of  course,  be  sterilized  by  boiling  before 
injection. 

Diets. 

Meat. — Raw  meat  is  a  most  useful  diet  after  many 
operations  when  the  powers  of  digestion  are  impaired. 
The  ease  with  which  raw  meat  is  digested,  and  the  small 
amount  of  residue  which  it  leaves  behind  after  digestion, 
makes  it  a  diet  of  the  greatest  value  in  affections  of  the 
alimentary  tract.  The  best  way  of  preparing  raw  meat 
is  to  scrape  the  fibres  away  from  the  connective  tissue 
with  the  back  of  a  knife ;  the  pulp  thus  obtained  can  be 
mixed  with  a  small  quantity  of  ordinary  beef-tea,  and 
flavoured  with  celery  salt  or  other  suitable  flavouring. 
As  a  rule,  it  is  wise  not  to  tell  the  patients  that  they  are 
being  fed  with  raw  meat,  as  some  people  dislike  the  idea. 
Of  course,  it  is  most  important  to  insure  that  the  meat 
comes  from  a  reliable  source  and  is  quite  fresh.  Meat 
extracts,  such  as  beef-tea,  etc.,  are  of  no  value  as  foods, 
and  but  inferior  stimulants;  moreover,  they  are  very  liable 
to  set  up  diarrhoea.  In  order  that  such  extracts  as  beef- 
tea,  bovril,  Liebig,  etc.,  may  be  made  use  of  as  foods, 
they  would  have  to  be  administered  in  the  concentrated 
form  by  the  ounce  or  more  many  times  a  day. 

Milk. — Milk  leaves  a  larger  residue  in  the  intestine 
than  most  other  liquid  foods,  and  is  very  liable  to  undergo 
fermentation   and   give   rise   to  the   formation  of  large 


268    The  After-Treatment  of  Operations 

quantities  of  gas  in  the  intestinal  tract,  a  most  unfortu- 
nate circumstance  after  abdominal  operations. 

Of  all  fluid  diets  milk  has  probably  always  been  the 
most  popular,  though  the  reason  for  this  is  in  some  ways 
a  little  difficult  to  understand.  It  must  be  remembered 
that  milk  is  not  a  fluid  after  it  has  been  swallowed,  but 
that  within  a  quarter  of  an  hour  of  its  having  entered  the 
stomach  it  sets  into  a  tough  leathery  clot,  which  may 
offer  very  considerable  resistance  to  the  digestive  action 
of  the  stomach.  Milk  remains  a  considerable  time  in  the 
stomach  in  a  semi-solid  state ;  it  would  therefore  seem  to 
be  contra-indicated  in  all  operations  on  the  stomach. 
There  are  several  ways,  however,  in  which  the  clotting 
of  milk  can  be  altogether  prevented,  or  can  be  rendered 
much  less  dense  and  resistant  than  normally.  Thus, 
simple  dilution  with  water  will  make  the  clot  less  dense 
and  more  easily  digested.  A  better  way,  however,  is  to 
dilute  the  milk  with  hme-water  in  the  proportion  of 
I  part  of  lime-water  to  2  of  milk  ;  this  greatly  reduces  the 
density  of  the  clot.  The  addition  of  soda-water  to  the 
milk,  or  the  simple  aeration  of  it  by  means  of  a  '  sparklet,' 
will  render  the  clot  much  more  readily  digestible.  Boiled 
milk,  though  outside  the  stomach  it  clots  less  easily  than 
raw  milk,  in  the  stomach  clots  just  as  readily  and  into 
just  as  tough  a  mass  as  raw  milk.  With  regard  to  the 
ease  and  completeness  with  which  milk  is  absorbed  by 
the  intestine,  it  has  been  shown  that  when  milk  is  given 
entirely  by  itself  it  is  absorbed  worse  than  any  other 
animal  food.  Under  the  most  favourable  conditions  only 
about  go  per  cent,  of  the  available  potential  energy  ever 
reaches  the  blood,  the  remainder  leaving  the  body  as 
waste.  Children,  however,  seem  to  be  able  to  absorb 
milk  very  much  better  than  adults. 

Milk,  though  rich  in  proteids  and  fats,  does  not  contain 
enough  carbohydrates  to  make  it  an  ideal  diet ;  it  is  there- 
fore better  to  combine  it  with  some  other  diet,  such  as  in 
bread  and  milk,  and  gruel,  or  to  add  sufficient  sugar  to  it 
to  raise  the  proportion  of  carbohydrates  to  the  proper 
extent.  It  is,  however,  a  very  valuable  diet  in  many 
cases  after  operations.  It  is  easily  digested  with  but 
little   expenditure   of  energy,  and   although  it  leaves  a 


Appendix  269 

comparatively  large  residue,  it  does  not  cause  much  peris- 
talsis of  the  intestine.  The  large  amount  of  phosphates 
contained  in  milk  renders  it  valuable  as  a  diet  in  cases 
where  there  is  much  bone  formation  going  on,  as  after 
excisions,  etc. 

Koumiss. — This  is  a  preparation  of  milk  of  great  value 
in  cases  of  wasting  disease.  It  is  much  more  readily 
digested  and  absorbed  than  ordinary  milk,  and  thus  allows 
of  very  large  quantities  of  nourishment  being  given  to 
patients  whose  digestive  functions  are  not  working  pro- 
perly, and  who  would  therefore  be  unable  to  assimilate 
such  a  large  amount  of  nutriment  in  other  forms. 
Koumiss  is  prepared  from  mare's  milk  by  fermentation, 
and  contains  about  2  per  cent,  of  alcohol.  One  of  its 
great  advantages  as  a  diet  is  that  the  casein  is  in  such  a 
state  that  it  cannot  form  into  clots  in  the  stomach,  and 
is  already  partly  digested.  The  alcohol  and  carbonic 
acid  which  it  contains  are  of  value  in  assisting  its 
digestion  in  the  intestine. 

Kephir,  Avhich  is  a  similar  preparation  made  from 
cow's  milk,  is  almost  as  valuable  as  koumiss,  and  is 
easily  obtainable  in  England,  The  leading  dairy  com- 
panies now  supply  both  koumiss  and  kephir  at  reasonable 
prices. 

Eggs. — Eggs  are  very  well  absorbed  by  the  intestine, 
and  leave  a  very  small  residue.  Eggs  are  much  more 
rapidly  digested  than  milk :  i  pint  of  milk  remains 
three  and  a  half  hours  in  the  stomach ;  tv/o  lightly- 
boiled  eggs  remain  one  and  three-quarter  hours  in  the 
stomach.  The  food  value  of  one  egg  equals  ^  pint  of 
milk.  Twenty  eggs  would  be  required  to  supply  all 
the  proteid  material  required  by  a  healthy  individual  in 
twenty-four  hours. 

To  prepare  Egg-albumin. — Beat  up  the  white  of  four 
fresh  eggs  in  ^  pint  of  water  until  the  whole  is  thoroughly 
mixed,  then  add  lemon  and  sugar  to  taste,  or,  if  preferred, 
salt  or  celery  salt  may  be  added  instead. 

Plasmon,  which  is  very  similar  to  egg-albumin,  and 
has  the  advantage  of  being  cheaper,  is  prepared  as 
follows  : 

Add  three  tablespoonfuls  of  tepid  water  to  three  tea- 
spoonfuls  of  plasmon,  stir,  and  rub  into  a  paste  ;  then  add 


2/0    The  After-Treatment  of  Operations 

gradually  ^  pint  of  tepid  water,  place  on  the  fire,  bring  to 
the  boil,  stirring  well  all  the  time,  and  boil  for  two 
minutes.  This  can  now  be  added  to  milk  or  other  liquid 
beverage.  When  cold  the  dissolved  plasmon  will  form 
into  a  jelly,  which  when  whisked  will  turn  into  a  thick 
cream.  The  jelly  or  cream  can  be  added  to  food,  or  by 
the  addition  of  water  can  be  made  into  a  beverage  and 
flavoured  to  taste. 

All  the  casein  preparations,  such  as  plasmon,  protene, 
nutrose,  etc.,  have  the  disadvantage,  as  compared  with 
pure  egg-albumin,  that  they  clot  in  the  stomach  in  the 
same  way  as  milk.  Plasmon,  which  appears  in  many 
ways  to  be  the  best  of  these  preparations,  when  tested 
with  rennet  does  not  clot  into  nearly  so  firm  a  mass  as 
pure  milk,  but  into  a  very  light  friable  clot,  and,  if  lime- 
water  is  added,  does  not  seem  to  clot  at  all.  Plasmon 
and  the  other  casein  preparations  are  of  very  little  value 
for  rectal  alimentation,  as  they  seem  not  to  be  absorbed. 
Egg-albumin  is  a  much  better  form  of  proteid  for  this 
purpose. 

Gelatin. — Jellies  which  are  made  from  gelatin  form 
an  excellent  diet,  and  are  very  readily  digested ;  4  ounces 
of  good  jelly  equals  if  ounces  of  solids,  of  which  half  is 
gelatin  and  the  rest  sugar.  Gelatin  has  the  advantage 
of  being  digested  more  readily  by  the  stomach  than 
almost  any  other  food.  It  was  estimated  by  Uffelmann 
that  peptonization  is  complete  within  one  hour.  Gelatin 
must  not,  however,  be  looked  upon  as  a  substitute  for 
proteid,  but  rather  as  a  useful  addition  to  other  diets. 
Its  chief  value  lies  in  its  property  of  economizing  proteid. 
It  is  on  this  account  that  it  has  been  called  a  '  proteid- 
sparer.' 

Sugar. — One  of  the  great  advantages  of  sugar  as  a 
diet  is  the  ease  with  which  it  can  be  absorbed.  Grape- 
sugar  (dextrose)  can  pass  into  the  blood  without  any 
digestion,  and  is  therefore  valuable  in  conditions  where 
the  digestive  power  is  impaired.  It  has  been  repeatedly 
proved  that,  as  a  muscle-former,  sugar  is  extremely 
valuable,  and  therefore  it  would  seem  to  be  indicated  as 
a  diet  in  combating  muscle  waste.  The  value  of  sugar 
as  part  of  an  invalid  diet  is  not  sufficiently  recognised ; 


Appendix  271 

the  ease  with  which  it  is  absorbed,  its  high  nutritive 
value,  and  its  high  potential  energy,  all  help  to  make  it 
one  of  the  most  useful  forms  of  diet  in  convalescent 
states. 

Unfortunately,  all  forms  of  sugar  tend  to  undergo 
fermentation  if  long  retained  in  the  alimentary  tract. 
Also  sugar  in  a  concentrated  form  is  irritating  to  mucous 
membranes.  It  is  therefore  important  when  using  sugar 
as  a  diet  not  to  give  it  in  too  large  quantities  at  a  time, 
and  not  to  give  it  in  too  concentrated  a  form.  When 
patients  object  to  a  sweet  diet,  milk-sugar,  which  is  almost 
free  from  a  sweet  taste,  can  be  used  in  place  of  other 
forms  of  sugar. 

REFERENCES. 

'  Food  and  the  Principles  of  Dietetics  '  :  Robert  Hutchison. 
'  Encyclopaedia  Medica. ' 


INDEX 


AnDOMEN,  operations  on  the,  169 
Abdominal  belts,  196 
Adenoids,  removal  of,  131 

hsemorrhage  after,  63 
rash  after,  135 
Adhesions,  192 
Adrenalin    in    the    treatment    of 

shock,  93 
Amputation  of  breast,  158 
of  limbs,  250 
secondary,  49 
Anaesthesia,    complications    after, 

97. 
Aperients,  use  of,  173 
Appendicitis,  205 
Artificial  appliances,  145,  154 
limbs,  255 

when  to  fit,  253 
respiration  in  the  treatment 
of  shock,  94 

Bedsore,  18 

Belts,  after  laparotomy,  196 

colotomy,  237 
Brain,  operations  on  the,  141 
Breast,  amputation  of  the,  15S 
Breathing  exercises,  165 
Bullet  wounds,  44 

Calcium  chloride  in  treatment  of 

hsemorrhage,  55 
Carbolic  acid  poisoning,  128 
Catheter  fever,  217 
Cervical    glands,    operation    for, 

.^57 
Circumcision,  224 

haemorrhage  after,  67 


Cleft  palate,  obturators  for,  145 

operation  for,  144 
Colic,  renal,  214 
Collapse,  82 
Colotomy,  235 
belts,  237 
Cystitis  in  women,  4,  226 
Cystotomy,  219 

Delirium  tremens,  22 
Diet  after  anaesthetics,  105 

after  laparotomy,  176 
Diets,  267 

Dilatation  of  stomach,  post-opera- 
tive, 193 
Distension,  171,  182 
Drainage  in  septic  bullet  wounds, 
46 

tube,  removal  of,  34 
Drug  habits,  15 

poisoning,  126 
Drugs  for  relief  of  pain,  13 

in  the  treatment  of  shock,  92 

Egg  albumin,  178 
Elbow,  excision  of,  241 
Empyema,  treatment  of,  160 
Enema  ra'^hes,  123 
Enemata,  nutrient,  264 
Epididymo-orchitis,  209 
Exercises,  248 

Fsecal  fistula,  186 
Fissure  in  ano,  235 
Fistula,  biliary,  204 

faecal,  186 

operation  for,  160 


273 


274 


Index 


Flatulence,  17 

Fomentations,  39^  46 

Foreign  bodies  in  gunshot  wounds, 

44 
left  in  abdomen,  194 
Fractures      complicating      bullet 
wounds,  49 

Gall-bladder,   operations  on  the, 

203 
Gauze  in  dressing  wounds,  38 
Genito-urinary    tract,    operations 

on  the,  215 
Glands  in  neck,  removal  of,  157 
Goitre,  operations  for,  155 

Hsematemesis,  104,  201 
Hsematuria,  213 
Hsemophilia,  56 
Hsemoptysis,  104 
Haemorrhage,  5 1 

after  special  operations,  62, 
203,  222 

constitutional  treatment   for, 
72 

internal,  61 

recurrent,  52 

secondary,  57 

from  bullet  wounds,  58 
Haemorrhoids,  231 
Harelip,  operations  for.  142 
Head,  operations  on  the,  141 
Hernia,  208 

cerebral,  142 

ventral,  193 
Hip,  excision  of  the,  245 
Hydrocele,  225 

Infarction,  109 

Insanity,  post-operative,  20,  103 
Insomnia,  10 

Intestinal  obstruction  after  opera- 
tion, 189 
Iodoform  poisoning,  127 
Irrigation  of  wounds,  37,  46 
rectal,  in  peritonitis,  197 

Jaundice,  a  cause  of  hemorrhage, 

Joints,  injuries  of,  50 
operations  on,  239 


Kidney,  operations  on  the,  211 
Knee,  excision  of  the,  243 

Laminectomy,  262 
Laparotomy,  169 

complications  after,  182 

diet  after,  176 

in  children,  8 
Leucocythemia,  57 
Lithotomy,  haemorrhage  after,  67 
Lithotrity,  222 

Mania,  20 
Massage,  247 
Mercurial  poisoning,  129 
Meteorism,  182 

Nasal  feeding,  266 

Neck,  operations  on  the,  149 

Nose,  operations  on  the,  139 

Obstruction  after  laparotomy,  189 
Obturators  for  cleft  palate,  145 
CEsophagotomy,  154 

Pain,  II,  12 

after  special  operations,  212, 
232,  251 
Paralysis,  post-angesthetic,  104 
Parotitis,  187 
Peritonitis,  185,  197 
Piles,  operation  for,  231 

pain  after,  232 
Pituitary    extract     for     relief    of 
flatulence,  18 
in  the  treatment  of  shock, 

93 

Plugging  of  rectum,  70 
Pneumonia,  102,  198 
Position  after  operation,  3 

after  laparotomy,  7 

after      operations      on      the 
stomach,  201 

in  cases  of  shock,  85 
Post-anffisthetic  complications,  97 
Prone  position,  4 
Prostatectomy,  221 

Rashes,  post-operative,  116 

due  to  enemata,  123 
Rectal  feeding,  264 


Index 


275 


Rectum,  operations  on  the,  228 
haemorrhage  from  the,  69 
plugging  of  the,  70 

Retention  of  urine,  210,  234 

Saline  infusion  in   the  treatment 

of  shock,  87,  88 
Scarlet  fever,  pust-operative,  121 
Sepsis,  36 

treatment  of,  40 
Septicaemia,  41,  117 
Septic  bullet  wounds,  46 

rashes,  116 
Serum,  treatment  with,  41 
Shock,  symptoms  of,  75 

physiology  of,  76 

treatment  of,  82 

prevention  of,  83 
Shoulder,  excision  of  the,  243 
Sinus,  persistent,  50,  166,  252 
Sleeplessness  after  operation,  10 
Smoking,  15 
Stimulants   in    the    treatment   of 

shock,  86 
Stitch  suppuration,  185 
Stitches,  removal  of,  32 
Stomach,  acute  dilatation  of  the, 

193 
operations  on  the,  198 
Stricture  after  operation  for  piles, 
234 


Strychnine  poisoning,  130 
Subcutaneous  feeding,  266 

Telephone  probe,  46 

Temperature  after  operations,  26 

Thirst,  16 

Thrombosis,  106 

Thyroid  gland,  operations  on  the, 

Tongue,  excision  of  the,  138 
Tonsils,  removal  of,  136 

hemorrhage  after,  63 
Tooth-extraction,  137 

haemorrhage  after,  65 
Tracheotomy,  149 
Transfusion,  88 

Ursemia,  2I3 
Urethrotomy,  external,  224 

internal,  223 
Uterus,  operations  on  the,  226 

Vaccines  in  sepsis,  41 

Varicocele,  226 

Varicose  veins,  260 

Vomiting,  98 

persistent,  210,  213 
regurgitant,  170,  199 

Wounds,  31 

gunshot,  43 


THE  END 


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